Neuromuscular Monitoring in Anaesthesia

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ── Palette ──────────────────────────────────────────────────────────────────
const C = {
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// ── Fetch images ─────────────────────────────────────────────────────────────
const IMG_URLS = [
  "https://cdn.orris.care/cdss_images/0cdca82ee73f8cafc438a2ed2d07f4fc129c0acfd6a4eaa9b0a02858e7384017.png",  // ulnar nerve
  "https://cdn.orris.care/cdss_images/255397a14095e5d234e461b283b583729221de37a08283a6a5c9991fa08b0ee5.png",  // TOF unblocked
  "https://cdn.orris.care/cdss_images/8cc141547c1d93cbc58be13d70427ae6344b82a8825a094f861391854a98c0b9.png",  // single twitch
  "https://cdn.orris.care/cdss_images/79790f932c68d69e46b7a5c71bb542dee8f59054fe593eb52efe324510ed71f7.png",  // RNMB incidence chart
  "https://cdn.orris.care/cdss_images/133272c73f8ee1ba9a5a03bb35871b5b53bd9079da7b093701efa9312c9b1e8b.png",  // TOF blocked
];

console.log("Fetching images...");
let images = [];
try {
  images = JSON.parse(execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${IMG_URLS.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 50 * 1024 * 1024 }
  ).toString());
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} catch(e) {
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}

const img = (i) => images[i] && !images[i].error ? { data: images[i].base64 } : null;

// ── Helper functions ─────────────────────────────────────────────────────────
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Neuromuscular Monitoring in Anaesthesia";
pres.author = "Orris Medical";

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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ═══════════════════════════════════════════════════════════════════════════
{
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  s.addText("NEUROMUSCULAR", { x: 0.4, y: 1.3, w: 8, h: 0.7, fontSize: 36, bold: true, color: C.white, charSpacing: 2 });
  s.addText("MONITORING", { x: 0.4, y: 1.95, w: 8, h: 0.7, fontSize: 36, bold: true, color: C.accent, charSpacing: 2 });
  s.addText("IN ANAESTHESIA", { x: 0.4, y: 2.6, w: 8, h: 0.5, fontSize: 22, color: C.lightGrey, charSpacing: 4 });
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  s.addText("Miller's Anesthesia 10e  ·  Barash Clinical Anesthesia 9e  ·  Morgan & Mikhail 7e", {
    x: 0.4, y: 4.9, w: 9, h: 0.3, fontSize: 9, color: C.lightGrey, italic: true
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 2 – WHY MONITOR?
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = midSlide();
  addAccentBar(s);
  addSlideLabel(s, "Introduction");
  addTitle(s, "Why Monitor Neuromuscular Function?");

  // 3 key stat cards
  const stats = [
    { val: "40%", label: "of patients reversed with neostigmine have residual paralysis" },
    { val: "5%", label: "residual paralysis rate even with sugammadex reversal" },
    { val: "230M", label: "surgical procedures globally per year — impact is enormous" },
  ];
  stats.forEach((st, i) => {
    const x = 0.3 + i * 3.2;
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  addSubtitle(s, "Why clinical signs fail:", { y: 3.0 });
  addBody(s, [
    "5-second head lift: achieved by 11/12 volunteers despite TOF ratio ≤0.5",
    "Tidal volume, vital capacity, grip strength — all INSENSITIVE to residual block",
    "Time since last NMBD dose is NOT a reliable guide — interpatient variability is huge",
    "8.4% of patients had TOF ratio <0.80 even 4 hours after a single vecuronium dose",
  ], { y: 3.3, fs: 12 });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 3 – PERIPHERAL NERVE STIMULATOR
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = midSlide();
  addAccentBar(s);
  addSlideLabel(s, "Equipment");
  addTitle(s, "Peripheral Nerve Stimulator (PNS)");

  // Left column – text
  addBody(s, [
    "Battery-operated device delivering square-wave monophasic current",
    "Current: 10–80 mA  |  Pulse width: 100–300 µs",
    "Must generate ≥50 mA across 1,000 Ω for supramaximal stimulation",
    "Negative electrode (black) placed DISTALLY — 'Red toward the head'",
    "Proper skin prep reduces resistance from 100,000 → <5,000 Ω",
    "Silver-silver chloride electrodes, ideally 7–8 mm diameter",
  ], { y: 1.3, w: 5.4, fs: 12 });

  addSubtitle(s, "Common monitoring sites:", { y: 3.6 });
  const sites = ["Ulnar nerve → adductor pollicis (most common)", "Facial nerve → orbicularis oculi", "Posterior tibial nerve → flexor hallucis brevis"];
  const siteItems = sites.map((t, i) => ({ text: t, options: { bullet: { type: "bullet" }, color: C.offWhite, fontSize: 11.5, breakLine: i < sites.length - 1 } }));
  s.addText(siteItems, { x: 0.45, y: 3.95, w: 5.4, h: 1.3, valign: "top" });

  // Right – ulnar nerve image
  const ulnarImg = img(0);
  if (ulnarImg) {
    s.addImage({ ...ulnarImg, x: 5.8, y: 1.2, w: 3.9, h: 2.9, altText: "Ulnar nerve electrode placement" });
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  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 4 – STIMULATION PATTERNS OVERVIEW
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide();
  addAccentBar(s);
  addSlideLabel(s, "Stimulation Patterns");
  addTitle(s, "Patterns of Nerve Stimulation");

  const patterns = [
    { name: "Single Twitch (ST)", freq: "0.1–1 Hz", use: "Onset of block only; requires baseline", note: "Cannot detect fade" },
    { name: "Train-of-Four (TOF)", freq: "2 Hz × 4", use: "Intraoperative depth; recovery assessment", note: "No baseline needed" },
    { name: "Tetanus", freq: "50 or 100 Hz / 5 s", use: "Sensitive test; painful in awake patients", note: "Causes post-tetanic facilitation" },
    { name: "Post-Tetanic Count (PTC)", freq: "50 Hz tetanus → 1 Hz singles", use: "When TOF count = 0 (profound block)", note: "PTC ≥1 = deep block" },
    { name: "Double-Burst (DBS)", freq: "50 Hz bursts × 2", use: "Better visual/tactile fade detection than TOF", note: "DBS3,3 or DBS3,2" },
  ];

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    s.addText(p.freq, { x: x + 0.18, y: y + 0.36, w: 2.6, h: 0.25, fontSize: 10, color: C.accent });
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}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 5 – TRAIN-OF-FOUR (TOF) — detailed
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = midSlide();
  addAccentBar(s);
  addSlideLabel(s, "Train-of-Four");
  addTitle(s, "Train-of-Four (TOF) Stimulation");

  // Left – explanation
  addBody(s, [
    "4 successive 200-µs stimuli at 2 Hz (over 2 seconds)",
    "TOF Ratio = T4/T1 amplitude (normally 1.0)",
    "Nondepolarizing block → progressive FADE (T4 < T1)",
    "Depolarizing block (succinylcholine) → uniform depression, NO fade",
    "Can be repeated every 10–15 s without post-tetanic facilitation",
  ], { y: 1.3, w: 5.3, fs: 12.5 });

  addSubtitle(s, "TOF Count vs. Block depth:", { y: 3.3 });
  const rows = [
    ["4 twitches", "~75%", "Shallow / minimal"],
    ["3 twitches", "~80%", "Moderate"],
    ["2 twitches", "~85%", "Deep"],
    ["1 twitch",   "~90%", "Deep"],
    ["0 twitches", ">90%", "Use PTC"],
  ];
  const cols = [0.45, 2.35, 4.0];
  const headers = ["TOF Count", "Receptor Occ.", "Depth"];
  headers.forEach((h, ci) => {
    s.addText(h, { x: cols[ci], y: 3.65, w: 1.7, h: 0.3, fontSize: 10, bold: true, color: C.accent });
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  // Right – TOF image
  const tofImg = img(1);
  if (tofImg) {
    s.addImage({ ...tofImg, x: 5.6, y: 1.2, w: 4.1, h: 2.3, altText: "TOF unblocked waveform" });
  }
  const tofBlockedImg = img(4);
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    s.addImage({ ...tofBlockedImg, x: 5.6, y: 3.4, w: 4.1, h: 2.0, altText: "TOF blocked waveform" });
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  if (tofImg || tofBlockedImg) {
    s.addText("Top: normal TOF ratio 1.0  |  Bottom: fade after nondepolarizing block", {
      x: 5.6, y: 5.1, w: 4.1, h: 0.3, fontSize: 8, color: C.lightGrey, italic: true, align: "center"
    });
  }
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 6 – POST-TETANIC COUNT & DBS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide();
  addAccentBar(s);
  addSlideLabel(s, "PTC & DBS");
  addTitle(s, "Post-Tetanic Count & Double-Burst Stimulation");

  // PTC card
  addCard(s, 0.25, 1.15, 4.6, 3.9, "POST-TETANIC COUNT (PTC)", [
    "Used when TOF count = 0 (profound block)",
    "Method: 50 Hz tetanus × 5 s → wait 3 s → 1 Hz single twitches",
    "Count the twitches after tetanus = PTC",
    "PTC 1–2 → very deep; spontaneous TOF recovery 10–20 min",
    "PTC >10 → first TOF twitch expected within minutes",
    "PTC = 0 → complete block; cannot antagonise with neostigmine",
  ], { bg: C.card, border: C.accent });

  // DBS card
  addCard(s, 5.15, 1.15, 4.6, 3.9, "DOUBLE-BURST STIMULATION (DBS)", [
    "Two variations of tetany; less painful for awake patients",
    "DBS3,3: 3 bursts at 50 Hz → 750 ms gap → 3 bursts",
    "DBS3,2: 3 bursts at 50 Hz → 750 ms gap → 2 bursts",
    "More sensitive than TOF for VISUAL/TACTILE fade detection",
    "Fade between the two bursts = residual block",
    "Cannot distinguish between TOF ratios 0.6–0.9 subjectively",
  ], { bg: C.card, border: C.accentAlt, accent: C.accentAlt });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 7 – DEPTH OF BLOCK CLASSIFICATION
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = midSlide();
  addAccentBar(s);
  addSlideLabel(s, "Depth Classification");
  addTitle(s, "Six Levels of Neuromuscular Blockade");

  const depths = [
    { depth: "Complete",  occ: ">95%",   tof: "TOFC 0, PTC 0",          col: "C0392B" },
    { depth: "Deep",      occ: "90–95%", tof: "TOFC 0, PTC ≥1",         col: "E67E22" },
    { depth: "Moderate",  occ: "70–90%", tof: "TOFC 1–3",                col: "F4A261" },
    { depth: "Shallow",   occ: "60–70%", tof: "TOFC 4, ratio <0.4",      col: "27AE60" },
    { depth: "Minimal",   occ: "60–70%", tof: "TOFC 4, ratio 0.4–0.9",   col: "2ECC71" },
    { depth: "Recovered", occ: "<70%",   tof: "TOFC 4, ratio ≥0.9",      col: "00C6AE" },
  ];

  const headerY = 1.2;
  ["Depth", "Receptor Occupancy", "Quantitative Monitor Findings"].forEach((h, ci) => {
    const xs = [0.25, 2.8, 5.0];
    s.addText(h, { x: xs[ci], y: headerY, w: ci === 2 ? 4.8 : 2.4, h: 0.3, fontSize: 11, bold: true, color: C.accent });
  });

  depths.forEach((d, i) => {
    const y = 1.55 + i * 0.61;
    s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y, w: 9.5, h: 0.55, fill: { color: C.card }, line: { color: C.card } });
    s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y, w: 0.08, h: 0.55, fill: { color: d.col }, line: { color: d.col } });
    s.addText(d.depth, { x: 0.42, y: y + 0.08, w: 2.3, h: 0.38, fontSize: 12.5, bold: true, color: C.white });
    s.addText(d.occ, { x: 2.8, y: y + 0.08, w: 2.0, h: 0.38, fontSize: 12, color: C.offWhite });
    s.addText(d.tof, { x: 5.0, y: y + 0.08, w: 4.7, h: 0.38, fontSize: 12, color: C.offWhite });
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 8 – QUANTITATIVE MONITORING
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide();
  addAccentBar(s);
  addSlideLabel(s, "Quantitative Monitoring");
  addTitle(s, "Quantitative (Objective) Neuromuscular Monitors");

  s.addText("The ONLY reliable method to confirm full recovery and safely avoid reversal agents", {
    x: 0.35, y: 1.15, w: 9.3, h: 0.4, fontSize: 13, color: C.accentAlt, italic: true, bold: true
  });

  const monitors = [
    { name: "Mechanomyography\n(MMG)", detail: "Measures isometric force directly. Reference gold standard. Requires immobilised limb — impractical clinically.", bias: "Reference (0% bias)" },
    { name: "Electromyography\n(EMG)", detail: "Measures compound muscle action potential. Fast, accurate, unaffected by hand position. Underestimates vs MMG (bias −4.7%).", bias: "Biased goal: 0.85" },
    { name: "Acceleromyography\n(AMG)", detail: "Piezoelectric crystal measures thumb acceleration. Most common clinical device. Thumb must be free to move. Overestimates vs MMG.", bias: "Biased goal: ≥0.95" },
    { name: "Kinemyography\n(KMG)", detail: "Piezoelectric film measures thumb bend. Less common. Similar considerations to AMG.", bias: "Biased goal: ≥0.95" },
  ];

  monitors.forEach((m, i) => {
    const x = 0.25 + (i % 2) * 4.85;
    const y = 1.65 + Math.floor(i / 2) * 1.65;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.6, h: 1.55, fill: { color: C.card }, line: { color: i === 0 ? C.accentAlt : C.accent, pt: 1 } });
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.6, h: 0.32, fill: { color: i === 0 ? C.accentAlt : C.accent }, line: { color: i === 0 ? C.accentAlt : C.accent } });
    s.addText(m.name, { x: x + 0.1, y: y + 0.03, w: 4.3, h: 0.28, fontSize: 10, bold: true, color: C.darkBg });
    s.addText(m.detail, { x: x + 0.12, y: y + 0.36, w: 4.3, h: 0.85, fontSize: 10, color: C.offWhite, wrap: true, valign: "top" });
    s.addText(m.bias, { x: x + 0.12, y: y + 1.22, w: 4.3, h: 0.25, fontSize: 9.5, color: C.accent, italic: true });
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 9 – DIFFERENTIAL MUSCLE SENSITIVITY
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = midSlide();
  addAccentBar(s);
  addSlideLabel(s, "Muscle Sensitivity");
  addTitle(s, "Differential Muscle Sensitivity to NMBDs");

  s.addText("Not all muscles recover at the same rate — this drives extubation decisions", {
    x: 0.35, y: 1.15, w: 9.3, h: 0.35, fontSize: 12.5, color: C.lightGrey, italic: true
  });

  // Two columns: resistant vs sensitive
  // Left: resistant (recovers earlier)
  s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: 1.6, w: 4.5, h: 0.38, fill: { color: C.accent }, line: { color: C.accent } });
  s.addText("MORE RESISTANT (Recovers FIRST)", { x: 0.3, y: 1.65, w: 4.5, h: 0.28, fontSize: 11, bold: true, color: C.darkBg, align: "center" });
  const resistant = ["Diaphragm", "Laryngeal adductors", "Orbicularis oculi", "Rectus abdominis"];
  const resItems = resistant.map((t, i) => ({ text: t, options: { bullet: { type: "bullet" }, color: C.offWhite, fontSize: 13, breakLine: i < resistant.length - 1 } }));
  s.addText(resItems, { x: 0.5, y: 2.05, w: 4.1, h: 1.8, valign: "top" });

  // Right: sensitive
  s.addShape(pres.shapes.RECTANGLE, { x: 5.2, y: 1.6, w: 4.5, h: 0.38, fill: { color: C.accentAlt }, line: { color: C.accentAlt } });
  s.addText("MORE SENSITIVE (Recovers LAST)", { x: 5.2, y: 1.65, w: 4.5, h: 0.28, fontSize: 11, bold: true, color: C.darkBg, align: "center" });
  const sensitive = ["Adductor pollicis (thumb — standard monitor site)", "Pharyngeal muscles", "Genioglossus", "Upper airway muscles"];
  const sensItems = sensitive.map((t, i) => ({ text: t, options: { bullet: { type: "bullet" }, color: C.offWhite, fontSize: 13, breakLine: i < sensitive.length - 1 } }));
  s.addText(sensItems, { x: 5.4, y: 2.05, w: 4.1, h: 1.8, valign: "top" });

  // Key implication box
  s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: 3.95, w: 9.4, h: 1.0, fill: { color: C.card }, line: { color: C.accentAlt, pt: 1.5 } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0.3, y: 3.95, w: 0.1, h: 1.0, fill: { color: C.accentAlt }, line: { color: C.accentAlt } });
  s.addText([
    { text: "Clinical implication: ", options: { bold: true, color: C.accentAlt, fontSize: 12 } },
    { text: "The adductor pollicis is MORE sensitive than pharyngeal and upper airway muscles. Recovery of the thumb DOES confirm airway muscle recovery — but only with quantitative monitoring (TOF ratio ≥0.9). Subjective assessment cannot reliably detect residual pharyngeal dysfunction.", options: { color: C.offWhite, fontSize: 12 } }
  ], { x: 0.5, y: 4.02, w: 9.0, h: 0.86, valign: "middle", wrap: true });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 10 – RESIDUAL NEUROMUSCULAR BLOCK
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide();
  addAccentBar(s);
  addSlideLabel(s, "Residual Block");
  addTitle(s, "Residual Neuromuscular Block (RNMB)");

  s.addText("Defined as TOF ratio <0.9 at extubation or in the PACU", {
    x: 0.35, y: 1.15, w: 9.3, h: 0.35, fontSize: 12.5, color: C.accentAlt, bold: true
  });

  // Left column – consequences
  addSubtitle(s, "Consequences of TOF ratio <0.9:", { y: 1.6 });
  addBody(s, [
    "Impaired pharyngeal function → aspiration risk",
    "Upper airway obstruction",
    "Impaired hypoxic ventilatory response",
    "Blurry vision, diplopia, facial weakness",
    "Increased PACU stay + nursing interventions",
    "Increased postoperative pulmonary complications",
    "Prolonged ICU ventilator weaning",
  ], { y: 1.95, w: 4.8, fs: 11.5 });

  // Right – incidence chart image
  const chartImg = img(3);
  if (chartImg) {
    s.addImage({ ...chartImg, x: 5.1, y: 1.3, w: 4.6, h: 3.5, altText: "RNMB incidence by time after NMBD" });
    s.addText("% patients with residual block by time since NMBD dose (Debaeene et al.)", {
      x: 5.1, y: 4.8, w: 4.6, h: 0.4, fontSize: 8.5, color: C.lightGrey, italic: true, align: "center"
    });
  } else {
    addCard(s, 5.1, 1.3, 4.6, 3.5, "INCIDENCE DATA (Debaeene et al.)", [
      "<60 min: 60% had TOF <0.90",
      "60–90 min: 62% had TOF <0.90",
      "90–120 min: 45% had TOF <0.90",
      ">120 min: 35% had TOF <0.90",
      "Even 4h after vecuronium: 8.4% still <0.80",
    ]);
  }
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 11 – REVERSAL AGENTS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = midSlide();
  addAccentBar(s);
  addSlideLabel(s, "Reversal Agents");
  addTitle(s, "Reversal of Neuromuscular Block");

  // Neostigmine card
  addCard(s, 0.25, 1.2, 4.6, 4.0, "NEOSTIGMINE (Anticholinesterase)", [
    "Inhibits acetylcholinesterase → ↑ ACh at NMJ",
    "Must co-administer glycopyrrolate or atropine",
    "Dose: 20–70 mcg/kg IV",
    "Onset: 5–10 min  |  Duration: 60–120 min",
    "Most effective at MINIMAL block (TOFC 4, ratio 0.4–0.9)",
    "Do NOT give at TOFC 0–2 — risk of paradoxical weakness",
    "Residual paralysis rate: ~30–40%",
  ], { bg: C.card, border: C.accent });

  // Sugammadex card
  addCard(s, 5.15, 1.2, 4.6, 4.0, "SUGAMMADEX (Selective Binding Agent)", [
    "Encapsulates steroidal NMBDs (rocuronium >> vecuronium)",
    "Immediate reversal (no PTC): 16 mg/kg",
    "Deep block (PTC ≥1, TOFC 0): 4 mg/kg",
    "Moderate block (TOFC 1–2): 2–4 mg/kg",
    "Shallow/minimal (TOFC ≥2): 2 mg/kg",
    "Residual paralysis rate: ~5%",
    "Safe in cholinesterase deficiency",
  ], { bg: C.card, border: C.accentAlt, accent: C.accentAlt });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 12 – CLINICAL DECISION GUIDE
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide();
  addAccentBar(s);
  addSlideLabel(s, "Clinical Guide");
  addTitle(s, "Monitoring-Guided Clinical Decisions");

  const rows2 = [
    { goal: "Confirm intubating conditions", mon: "TOFC = 0 (or PTC = 0 for complete block)", action: "Proceed with intubation" },
    { goal: "Deep intraoperative block", mon: "TOFC = 0, PTC 1–5", action: "Maintain block; no reversal yet" },
    { goal: "Moderate intraoperative block", mon: "TOFC 1–3", action: "Surgical relaxation adequate" },
    { goal: "Timing of neostigmine", mon: "TOFC = 4, ratio 0.4–0.9 (minimal block)", action: "Give neostigmine 20–70 mcg/kg" },
    { goal: "Sugammadex — deep reversal", mon: "TOFC = 0, PTC ≥1", action: "Sugammadex 4 mg/kg" },
    { goal: "Sugammadex — moderate block", mon: "TOFC 1–3", action: "Sugammadex 2–4 mg/kg" },
    { goal: "Safe extubation", mon: "TOF ratio ≥0.9 (quantitative)", action: "Extubation appropriate" },
  ];

  const colX = [0.25, 3.5, 6.85];
  const colW = [3.1, 3.25, 2.95];
  const headers = ["Clinical Goal", "Monitoring Criterion", "Action"];
  headers.forEach((h, ci) => {
    s.addShape(pres.shapes.RECTANGLE, { x: colX[ci], y: 1.2, w: colW[ci], h: 0.32, fill: { color: C.accent }, line: { color: C.accent } });
    s.addText(h, { x: colX[ci] + 0.08, y: 1.22, w: colW[ci] - 0.1, h: 0.28, fontSize: 10, bold: true, color: C.darkBg });
  });

  rows2.forEach((r, i) => {
    const y = 1.55 + i * 0.54;
    const bg = i % 2 === 0 ? C.card : C.cardLight;
    colX.forEach((cx, ci) => {
      s.addShape(pres.shapes.RECTANGLE, { x: cx, y, w: colW[ci], h: 0.5, fill: { color: bg }, line: { color: C.darkBg } });
    });
    s.addText(r.goal, { x: colX[0] + 0.08, y: y + 0.05, w: colW[0] - 0.12, h: 0.4, fontSize: 10, color: C.offWhite, wrap: true, valign: "middle" });
    s.addText(r.mon, { x: colX[1] + 0.08, y: y + 0.05, w: colW[1] - 0.12, h: 0.4, fontSize: 10, color: C.accent, wrap: true, valign: "middle" });
    s.addText(r.action, { x: colX[2] + 0.08, y: y + 0.05, w: colW[2] - 0.12, h: 0.4, fontSize: 10, color: C.accentAlt, wrap: true, valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 13 – GUIDELINES & EVIDENCE
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = midSlide();
  addAccentBar(s);
  addSlideLabel(s, "Guidelines");
  addTitle(s, "Guidelines & Current Evidence");

  // Countries
  s.addText("Countries with quantitative NM monitoring guidelines:", {
    x: 0.35, y: 1.15, w: 9.3, h: 0.32, fontSize: 12, bold: true, color: C.accent
  });
  const countries = ["Canada", "France", "Spain", "Australia", "New Zealand", "Czech Republic", "Portugal", "Japan", "USA (recently published)"];
  countries.forEach((c, i) => {
    const x = 0.35 + (i % 3) * 3.1;
    const y = 1.5 + Math.floor(i / 3) * 0.45;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 2.9, h: 0.36, fill: { color: C.card }, line: { color: C.accent, pt: 0.5 } });
    s.addShape(pres.shapes.OVAL, { x: x + 0.1, y: y + 0.09, w: 0.18, h: 0.18, fill: { color: C.accent }, line: { color: C.accent } });
    s.addText(c, { x: x + 0.35, y: y + 0.06, w: 2.5, h: 0.24, fontSize: 11, color: C.offWhite });
  });

  // Recent evidence
  addSubtitle(s, "Recent Evidence (2024–2026):", { y: 3.15 });
  addBody(s, [
    "Bijkerk et al. Br J Anaesth 2025 — RNMB in PACU remains common; supports routine quantitative monitoring [PMID: 39443187]",
    "Alderman & Smith-Steinert J Perianesth Nurs 2026 — Evidence-based summary: recognition and treatment of postoperative residual paralysis [PMID: 41460225]",
    "Vanlinthout et al. Paediatr Anaesth 2024 — Network meta-analysis of NMB recovery in paediatric patients [PMID: 38676354]",
  ], { y: 3.5, fs: 11 });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 14 – KEY POINTS (SUMMARY)
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = darkSlide();
  // Left accent strip
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.12, h: 5.625, fill: { color: C.accent }, line: { color: C.accent } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.3, w: 10, h: 0.12, fill: { color: C.accent }, line: { color: C.accent } });

  s.addText("KEY TAKEAWAYS", { x: 0.35, y: 0.25, w: 9.3, h: 0.4, fontSize: 10, bold: true, color: C.accent, charSpacing: 4 });

  const points = [
    { n: "01", t: "NMBDs do not cause amnesia or consciousness loss — paralysis only." },
    { n: "02", t: "Clinical signs (head lift, grip) are insensitive and cannot exclude residual block." },
    { n: "03", t: "TOF is the clinical standard; TOF ratio ≥0.9 (quantitative) = safe extubation." },
    { n: "04", t: "PTC guides management during deep block when TOFC = 0." },
    { n: "05", t: "Adductor pollicis recovers last — monitoring it protects airway muscle function." },
    { n: "06", t: "Quantitative monitoring reduces PACU RNMB and respiratory complications." },
    { n: "07", t: "Neostigmine: minimal block only. Sugammadex: any depth, lower residual rate." },
  ];

  points.forEach((p, i) => {
    const y = 0.78 + i * 0.66;
    s.addShape(pres.shapes.OVAL, { x: 0.25, y: y + 0.05, w: 0.5, h: 0.5, fill: { color: C.accent, transparency: 15 }, line: { color: C.accent } });
    s.addText(p.n, { x: 0.27, y: y + 0.08, w: 0.46, h: 0.4, fontSize: 11, bold: true, color: C.darkBg, align: "center" });
    s.addText(p.t, { x: 0.88, y: y + 0.06, w: 8.8, h: 0.5, fontSize: 12.5, color: C.offWhite, valign: "middle" });
  });
}

// ── Write file ─────────────────────────────────────────────────────────────
const OUT = "/home/daytona/workspace/neuromuscular-monitoring/Neuromuscular_Monitoring_Anaesthesia.pptx";
pres.writeFile({ fileName: OUT }).then(() => {
  console.log("✓ Saved:", OUT);
}).catch(err => {
  console.error("Error:", err);
  process.exit(1);
});