const pptxgen = require("pptxgenjs"); const pres = new pptxgen(); pres.layout = "LAYOUT_16x9"; pres.author = "MD Anesthesia"; pres.title = "Massive Blood Transfusion Protocol in Anesthesia"; // ─── COLOR PALETTE ───────────────────────────────────────────────────────── const C = { darkRed: "8B0000", crimson: "B22222", blood: "C0392B", darkBg: "1A1A2E", darkNav: "16213E", panelBg: "0F3460", accent: "E94560", gold: "F0C040", white: "FFFFFF", lightGray: "E8E8E8", paleRed: "FDECEA", offWhite: "F5F5F5", green: "27AE60", orange: "E67E22", teal: "1ABC9C", steelBlue: "2980B9", }; // ─── HELPER: add background rect ─────────────────────────────────────────── function bg(slide, color) { slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color } }); } // ─── HELPER: section title bar ───────────────────────────────────────────── function titleBar(slide, text, sub) { // left accent stripe slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.12, h: 5.625, fill: { color: C.crimson } }); // top band slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.1, fill: { color: C.darkNav } }); slide.addText(text, { x: 0.2, y: 0.1, w: 9.5, h: 0.7, fontSize: 26, bold: true, color: C.white, fontFace: "Calibri", margin: 0 }); if (sub) { slide.addText(sub, { x: 0.2, y: 0.75, w: 9.5, h: 0.35, fontSize: 13, color: C.gold, fontFace: "Calibri", margin: 0 }); } } // ─── HELPER: colored pill badge ──────────────────────────────────────────── function pill(slide, text, x, y, w, h, fill, textColor) { slide.addShape(pres.ShapeType.roundRect, { x, y, w, h, fill: { color: fill }, line: { color: fill }, rectRadius: 0.08 }); slide.addText(text, { x, y, w, h, fontSize: 11, bold: true, color: textColor || C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); } // ─── HELPER: card ────────────────────────────────────────────────────────── function card(slide, x, y, w, h, header, headerBg, items, itemColor) { slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color: C.white }, line: { color: headerBg, width: 1.5 }, shadow: { type: "outer", blur: 3, offset: 2, angle: 45, color: "AAAAAA" } }); slide.addShape(pres.ShapeType.rect, { x, y, w, h: 0.35, fill: { color: headerBg } }); slide.addText(header, { x, y, w, h: 0.35, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); const bulletItems = items.map((t, i) => ({ text: t, options: { bullet: { type: "bullet", code: "25CF", color: headerBg }, color: itemColor || "222222", fontSize: 10, fontFace: "Calibri", breakLine: i < items.length - 1 } })); slide.addText(bulletItems, { x: x + 0.1, y: y + 0.38, w: w - 0.2, h: h - 0.4, valign: "top", margin: 2 }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 1 — TITLE // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.darkBg); // blood drop decoration sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.crimson } }); sl.addShape(pres.ShapeType.rect, { x: 9.82, y: 0, w: 0.18, h: 5.625, fill: { color: C.crimson } }); sl.addShape(pres.ShapeType.rect, { x: 0, y: 5.3, w: 10, h: 0.325, fill: { color: C.panelBg } }); // Red horizontal accent bar mid sl.addShape(pres.ShapeType.rect, { x: 1.5, y: 2.05, w: 7, h: 0.06, fill: { color: C.crimson } }); sl.addShape(pres.ShapeType.rect, { x: 1.5, y: 3.35, w: 7, h: 0.06, fill: { color: C.crimson } }); sl.addText("MASSIVE BLOOD TRANSFUSION", { x: 0.5, y: 0.7, w: 9, h: 0.85, fontSize: 38, bold: true, color: C.white, align: "center", fontFace: "Calibri", charSpacing: 2, margin: 0 }); sl.addText("PROTOCOL (MTP)", { x: 0.5, y: 1.45, w: 9, h: 0.65, fontSize: 32, bold: true, color: C.accent, align: "center", fontFace: "Calibri", margin: 0 }); sl.addText("Anesthesia Perspective — MD Seminar", { x: 1, y: 2.2, w: 8, h: 0.5, fontSize: 18, color: C.gold, align: "center", fontFace: "Calibri", margin: 0 }); sl.addText([ { text: "Morgan & Mikhail's Clinical Anesthesiology | Miller's Anesthesia | Sabiston Textbook of Surgery", options: { fontSize: 11, color: "AAAAAA", breakLine: true } }, { text: "Rosen's Emergency Medicine | Henry's Clinical Diagnosis | PROPPR Trial Evidence", options: { fontSize: 11, color: "AAAAAA" } } ], { x: 0.5, y: 3.5, w: 9, h: 0.6, align: "center", fontFace: "Calibri", margin: 0 }); sl.addText("Department of Anaesthesiology & Critical Care • May 2026", { x: 0.5, y: 5.3, w: 9, h: 0.3, fontSize: 10, color: C.lightGray, align: "center", fontFace: "Calibri", margin: 0 }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 2 — OVERVIEW / TABLE OF CONTENTS // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.offWhite); titleBar(sl, "Presentation Overview", "A structured approach to MTP in Anesthesia Practice"); const topics = [ ["01", "Definition & Triggers", "When to declare MTP"], ["02", "Pathophysiology", "Lethal Triad — Hypothermia · Acidosis · Coagulopathy"], ["03", "Blood Products & Ratios", "1:1:1 vs 1:1:2 — PROPPR Trial Evidence"], ["04", "Damage Control Resuscitation", "Permissive hypotension, DCR principles"], ["05", "Point-of-Care Monitoring", "TEG / ROTEM — Viscoelastic guided therapy"], ["06", "Adjuncts", "TXA, Calcium, Vasopressors, Warming"], ["07", "Complications", "Hypothermia, Coagulopathy, TACO, TRALI, Electrolytes"], ["08", "Anesthesia Checklist", "Practical step-by-step intraoperative guide"], ]; topics.forEach(([num, title, sub], i) => { const col = i % 2; const row = Math.floor(i / 2); const x = 0.3 + col * 4.9; const y = 1.25 + row * 1.05; sl.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 0.88, fill: { color: col === 0 ? C.darkNav : C.panelBg }, line: { color: C.crimson, width: 1.5 } }); sl.addShape(pres.ShapeType.rect, { x, y, w: 0.5, h: 0.88, fill: { color: C.crimson } }); sl.addText(num, { x, y, w: 0.5, h: 0.88, fontSize: 18, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(title, { x: x + 0.55, y: y + 0.04, w: 3.9, h: 0.38, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", margin: 0 }); sl.addText(sub, { x: x + 0.55, y: y + 0.42, w: 3.9, h: 0.36, fontSize: 10, color: C.gold, fontFace: "Calibri", margin: 0 }); }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 3 — DEFINITION & TRIGGERS // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.darkBg); titleBar(sl, "Definition & Triggers of MTP", "Morgan & Mikhail 7e · Henry's Clinical Diagnosis · Rosen's EM"); // Definition box sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.2, w: 9.5, h: 0.75, fill: { color: C.panelBg }, line: { color: C.crimson, width: 2 } }); sl.addText([ { text: "DEFINITION: ", options: { bold: true, color: C.gold, fontSize: 13 } }, { text: "Replacement of ≥1 blood volume within 24 hours | OR ≥10 units pRBC in 24 h | OR active blood loss >150 mL/min", options: { color: C.white, fontSize: 13 } } ], { x: 0.35, y: 1.2, w: 9.3, h: 0.75, valign: "middle", fontFace: "Calibri", margin: 4 }); // Practical triggers sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 2.05, w: 4.6, h: 2.85, fill: { color: C.darkNav }, line: { color: C.steelBlue, width: 1 } }); sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 2.05, w: 4.6, h: 0.35, fill: { color: C.steelBlue } }); sl.addText("PRACTICAL TRIGGERS", { x: 0.25, y: 2.05, w: 4.6, h: 0.35, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText([ { text: "≥3 units pRBC in 1 hour with ongoing hemorrhage", options: { bullet: true, breakLine: true } }, { text: "≥4 blood components in 30 minutes", options: { bullet: true, breakLine: true } }, { text: "Shock Index (HR/SBP) > 1.0", options: { bullet: true, breakLine: true } }, { text: "Assessment of Blood Consumption (ABC) score ≥ 2", options: { bullet: true, breakLine: true } }, { text: "Anticipated massive surgical loss (AAA, liver Tx, trauma)", options: { bullet: true } }, ].map((i, idx, arr) => ({ text: i.text, options: { ...i.options, color: C.lightGray, fontSize: 11, fontFace: "Calibri", breakLine: idx < arr.length - 1 } })), { x: 0.35, y: 2.45, w: 4.4, h: 2.4, valign: "top", margin: 2 }); // Etiology box sl.addShape(pres.ShapeType.rect, { x: 5.15, y: 2.05, w: 4.6, h: 2.85, fill: { color: C.darkNav }, line: { color: C.crimson, width: 1 } }); sl.addShape(pres.ShapeType.rect, { x: 5.15, y: 2.05, w: 4.6, h: 0.35, fill: { color: C.crimson } }); sl.addText("COMMON ETIOLOGIES", { x: 5.15, y: 2.05, w: 4.6, h: 0.35, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); const etio = ["Major trauma / polytrauma", "Ruptured aortic aneurysm (AAA)", "GI hemorrhage (esp. with liver disease)", "Obstetric emergencies (PPH, uterine rupture)", "Liver transplantation", "Cardiac / vascular surgery"]; sl.addText(etio.map((t, i) => ({ text: t, options: { bullet: { code: "25B6", color: C.crimson }, color: C.lightGray, fontSize: 11, fontFace: "Calibri", breakLine: i < etio.length - 1 } })), { x: 5.25, y: 2.45, w: 4.4, h: 2.4, valign: "top", margin: 2 }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 4 — LETHAL TRIAD // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.darkBg); titleBar(sl, "Pathophysiology — The Lethal Triad", "Mulholland & Greenfield Surgery · Sabiston · Miller's Anesthesia"); // Triangle representation const triItems = [ { label: "HYPOTHERMIA", sub: "< 35°C", desc: "↓ coagulation factor activity\n↓ platelet function\n↓ cardiac output", color: C.steelBlue, x: 3.5, y: 1.15 }, { label: "ACIDOSIS", sub: "pH < 7.2", desc: "↓ coagulation enzyme activity\n↓ Ca²⁺ sensitivity\nLactic acidosis from hypoperfusion", color: C.crimson, x: 0.3, y: 3.1 }, { label: "COAGULOPATHY", sub: "TIC / DIC", desc: "Dilution of factors & platelets\nConsumption via DIC\nDysfunction (hypothermia/acidosis)", color: C.orange, x: 6.65, y: 3.1 }, ]; triItems.forEach(({ label, sub, desc, color, x, y }) => { sl.addShape(pres.ShapeType.roundRect, { x, y, w: 3.1, h: 1.9, fill: { color: C.panelBg }, line: { color, width: 2.5 }, rectRadius: 0.1 }); sl.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h: 0.4, fill: { color } }); sl.addText(label, { x, y, w: 3.1, h: 0.4, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(sub, { x, y: y + 0.4, w: 3.1, h: 0.3, fontSize: 11, bold: true, color: color, align: "center", fontFace: "Calibri", margin: 0 }); sl.addText(desc, { x: x + 0.1, y: y + 0.72, w: 2.9, h: 1.12, fontSize: 10, color: C.lightGray, fontFace: "Calibri", margin: 0 }); }); // Center circle sl.addShape(pres.ShapeType.ellipse, { x: 3.95, y: 2.75, w: 2.1, h: 0.85, fill: { color: C.crimson } }); sl.addText("DEATH", { x: 3.95, y: 2.75, w: 2.1, h: 0.85, fontSize: 16, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); // Arrows between sl.addText("⟵ feeds ⟶", { x: 3.8, y: 3.8, w: 2.4, h: 0.3, fontSize: 9, color: "999999", align: "center", fontFace: "Calibri", margin: 0 }); // Bottom note sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 5.1, w: 9.5, h: 0.4, fill: { color: C.panelBg } }); sl.addText("Each element drives the others — modern DCR targets ALL THREE simultaneously to break the cycle", { x: 0.3, y: 5.1, w: 9.4, h: 0.4, fontSize: 11, italic: true, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 5 — BLOOD PRODUCTS & RATIOS // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.offWhite); titleBar(sl, "Blood Products & Transfusion Ratios", "PROPPR RCT · Henry's · Rosen's · Goldman-Cecil · Morgan & Mikhail"); // 1:1:1 big badge sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.25, w: 3.2, h: 3.8, fill: { color: C.darkNav }, line: { color: C.crimson, width: 2 } }); sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.25, w: 3.2, h: 0.45, fill: { color: C.crimson } }); sl.addText("RECOMMENDED RATIO", { x: 0.25, y: 1.25, w: 3.2, h: 0.45, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText("1 : 1 : 1", { x: 0.25, y: 1.7, w: 3.2, h: 1.1, fontSize: 46, bold: true, color: C.gold, align: "center", fontFace: "Calibri", margin: 0 }); sl.addText("pRBC : FFP : Platelets", { x: 0.25, y: 2.75, w: 3.2, h: 0.4, fontSize: 13, bold: true, color: C.white, align: "center", fontFace: "Calibri", margin: 0 }); sl.addShape(pres.ShapeType.rect, { x: 0.5, y: 3.2, w: 2.7, h: 0.04, fill: { color: C.crimson } }); sl.addText([ { text: "PROPPR Trial (JAMA 2015): ", options: { bold: true, color: C.gold } }, { text: "1:1:1 reduced 24-h exsanguination vs 1:1:2 — no difference in 30-day mortality", options: { color: C.lightGray } }, ], { x: 0.3, y: 3.28, w: 3.0, h: 1.7, fontSize: 10, fontFace: "Calibri", margin: 2 }); // Component cards const comps = [ { name: "pRBC", detail: "Hct ~70%\nVolume: ~350 mL/unit\nShelf life: 35–42 days (4°C)\nIndication: Hb < 7–8 g/dL\n(or ongoing hemorrhage)", color: C.crimson }, { name: "FFP", detail: "Contains all factors\nVolume: ~200 mL/unit\nIndication: PT/aPTT > 1.5× UNL\nGive ABO-compatible\nThaw in 30 min", color: C.steelBlue }, { name: "Platelets", detail: "1 apheresis unit =\n6–8 pooled units\nVolume: 50–70 mL\nIndication: plt < 50 × 10⁹/L\nStore 20–24°C; 5 days", color: C.teal }, { name: "Cryo-\nprecipitate", detail: "Rich in: Fibrinogen,\nFactor VIII, vWF, FXIII\nIndication: Fibrinogen < 1 g/L\nGive 10 units (pool)\n= 2–4 g fibrinogen", color: C.orange }, ]; comps.forEach(({ name, detail, color }, i) => { const x = 3.7 + i * 1.55; sl.addShape(pres.ShapeType.rect, { x, y: 1.25, w: 1.45, h: 3.8, fill: { color: C.white }, line: { color, width: 1.5 } }); sl.addShape(pres.ShapeType.rect, { x, y: 1.25, w: 1.45, h: 0.45, fill: { color } }); sl.addText(name, { x, y: 1.25, w: 1.45, h: 0.45, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(detail, { x: x + 0.06, y: 1.75, w: 1.33, h: 3.25, fontSize: 9.5, color: "222222", fontFace: "Calibri", margin: 2, valign: "top" }); }); // Whole blood note sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 5.1, w: 9.5, h: 0.38, fill: { color: C.panelBg } }); sl.addText("Cold-stored Low-Titer O Whole Blood (LTOWB): Emerging preference in trauma — provides all components in physiologic balance (Sabiston 2024)", { x: 0.3, y: 5.1, w: 9.4, h: 0.38, fontSize: 10, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 6 — DAMAGE CONTROL RESUSCITATION // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.darkBg); titleBar(sl, "Damage Control Resuscitation (DCR)", "Miller's Anesthesia · Sabiston · Mulholland & Greenfield · Rockwood & Green"); sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.2, w: 9.5, h: 0.55, fill: { color: C.panelBg } }); sl.addText('"DCR combines an empiric hemostatic resuscitation strategy with permissive hypotension during Phase 1 uncontrolled hemorrhage — the goal is hemostasis, not normalization." — Miller\'s Anesthesia 10e', { x: 0.3, y: 1.2, w: 9.4, h: 0.55, fontSize: 10.5, italic: true, color: C.gold, valign: "middle", fontFace: "Calibri", margin: 4 }); const pillars = [ { title: "PERMISSIVE\nHYPOTENSION", items: ["Target SBP 80–90 mmHg\n(unless TBI present)", "Goal: palpable radial pulse\nin non-head-injured", "Avoid aggressive\ncrystalloid resuscitation", "Stops prior to\ndefinitive hemorrhage control"], color: C.steelBlue }, { title: "EARLY BLOOD\nPRODUCT USE", items: ["Initiate 1:1:1 pRBC:FFP:plt\nbefore labs available", "Avoid dilutional\ncoagulopathy", "Reduced total pRBC use\nby 25% in studies", "Type O pRBC\n+ type AB FFP if no type"], color: C.crimson }, { title: "DAMAGE CONTROL\nSURGERY", items: ["Abbreviated surgery\n→ ICU → re-look", "Achieve hemostasis &\ncontamination control", "Pack & close\n(staged approach)", "Anesthesia team role:\nbridging physiology"], color: C.orange }, { title: "AVOID\nCRYSTALLOID", items: ["Normal saline → hyper-\nchloremic acidosis", "Dilutes clotting factors\n& platelets", "Restricted use:\nonly as drug carrier", "Plasma-Lyte preferred\nif crystalloid needed"], color: C.teal }, ]; pillars.forEach(({ title, items, color }, i) => { const x = 0.25 + i * 2.38; sl.addShape(pres.ShapeType.rect, { x, y: 1.85, w: 2.22, h: 3.55, fill: { color: C.darkNav }, line: { color, width: 1.5 } }); sl.addShape(pres.ShapeType.rect, { x, y: 1.85, w: 2.22, h: 0.5, fill: { color } }); sl.addText(title, { x, y: 1.85, w: 2.22, h: 0.5, fontSize: 10.5, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); items.forEach((item, j) => { sl.addShape(pres.ShapeType.rect, { x: x + 0.1, y: 2.42 + j * 0.75, w: 2.02, h: 0.65, fill: { color: "0D2137" }, line: { color, width: 0.5 } }); sl.addText(item, { x: x + 0.1, y: 2.42 + j * 0.75, w: 2.02, h: 0.65, fontSize: 9, color: C.lightGray, align: "center", valign: "middle", fontFace: "Calibri", margin: 2 }); }); }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 7 — POC MONITORING (TEG / ROTEM) // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.offWhite); titleBar(sl, "Point-of-Care Coagulation Monitoring", "Miller's Anesthesia · Rosen's · Mulholland · Current Surgical Therapy 14e"); // TEG box sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.25, w: 4.65, h: 4.1, fill: { color: C.darkNav }, line: { color: C.steelBlue, width: 2 } }); sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 1.25, w: 4.65, h: 0.42, fill: { color: C.steelBlue } }); sl.addText("TEG (Thromboelastography)", { x: 0.25, y: 1.25, w: 4.65, h: 0.42, fontSize: 13, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); const tegItems = [ ["R time (reaction)", "Time to first clot formation; ↑ = factor deficiency", C.steelBlue], ["K time", "Clot kinetics; ↑ = fibrinogen deficiency", C.teal], ["Angle (α)", "Rate of clot strengthening; ↓ = fibrinogen/plt deficiency", C.orange], ["MA (max amplitude)", "Clot strength; ↓ = platelet dysfunction or thrombocytopenia", C.crimson], ["LY30 / EPL", "Fibrinolysis — ↑ = hyperfibrinolysis → TXA indicated", C.gold], ]; tegItems.forEach(([param, desc, col], i) => { sl.addShape(pres.ShapeType.roundRect, { x: 0.35, y: 1.78 + i * 0.68, w: 1.3, h: 0.52, fill: { color: col }, rectRadius: 0.05 }); sl.addText(param, { x: 0.35, y: 1.78 + i * 0.68, w: 1.3, h: 0.52, fontSize: 9.5, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(desc, { x: 1.72, y: 1.78 + i * 0.68, w: 3.1, h: 0.52, fontSize: 9.5, color: C.lightGray, valign: "middle", fontFace: "Calibri", margin: 2 }); }); // ROTEM box sl.addShape(pres.ShapeType.rect, { x: 5.1, y: 1.25, w: 4.65, h: 4.1, fill: { color: C.darkNav }, line: { color: C.crimson, width: 2 } }); sl.addShape(pres.ShapeType.rect, { x: 5.1, y: 1.25, w: 4.65, h: 0.42, fill: { color: C.crimson } }); sl.addText("ROTEM (Rotational Thromboelastometry)", { x: 5.1, y: 1.25, w: 4.65, h: 0.42, fontSize: 12, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); const rotemChannels = [ ["EXTEM", "Extrinsic pathway — screen overall clot formation", C.crimson], ["INTEM", "Intrinsic pathway — hemophilia, heparin effect", C.steelBlue], ["FIBTEM", "Fibrin clot strength (platelet-inhibited) — fibrinogen level", C.orange], ["APTEM", "Fibrinolysis screen — aprotinin reference channel", C.teal], ["MCF (FIBTEM)", "< 9 mm → fibrinogen < 1 g/L → give cryoprecipitate", C.gold], ]; rotemChannels.forEach(([param, desc, col], i) => { sl.addShape(pres.ShapeType.roundRect, { x: 5.2, y: 1.78 + i * 0.68, w: 1.3, h: 0.52, fill: { color: col }, rectRadius: 0.05 }); sl.addText(param, { x: 5.2, y: 1.78 + i * 0.68, w: 1.3, h: 0.52, fontSize: 9.5, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(desc, { x: 6.57, y: 1.78 + i * 0.68, w: 3.1, h: 0.52, fontSize: 9.5, color: C.lightGray, valign: "middle", fontFace: "Calibri", margin: 2 }); }); // Bottom note sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 5.1, w: 9.5, h: 0.38, fill: { color: C.panelBg } }); sl.addText("Evidence: TEG-guided resuscitation reduced mortality vs conventional coagulation assays in trauma (ITACTIC 2020) — viscoelastic testing preferred in MTP", { x: 0.3, y: 5.1, w: 9.4, h: 0.38, fontSize: 10, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 8 — ADJUNCTS // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.darkBg); titleBar(sl, "Adjunct Therapies in MTP", "Miller's Anesthesia · Tintinalli · Current Surgical Therapy 14e · Barash 9e"); const adjuncts = [ { title: "TRANEXAMIC ACID (TXA)", color: C.steelBlue, x: 0.25, y: 1.2, w: 4.6, h: 2.2, items: ["Antifibrinolytic — inhibits plasminogen → plasmin conversion", "CRASH-2 (20,211 pts): ↓ all-cause mortality when given within 3h", "MATTERS trial (military): ↓ mortality especially in MTP patients", "Dose: 1 g IV over 10 min, then 1 g over 8 h", "Give WITHIN 3 HOURS of injury — harm if given later", "Indicated when TEG/ROTEM shows hyperfibrinolysis (LY30 > 3%)"] }, { title: "CALCIUM SUPPLEMENTATION", color: C.orange, x: 5.15, y: 1.2, w: 4.6, h: 2.2, items: ["Citrate in banked blood chelates ionized Ca²⁺", "Hypocalcemia = ↓ cardiac contractility + coagulation impairment", "Monitor ionized Ca²⁺ every 5–10 units pRBC", "Treat if iCa < 1.1 mmol/L", "CaCl₂ 1 g IV preferred (3× more bioavailable than gluconate)", "Critical in liver failure — impaired citrate metabolism"] }, { title: "RECOMBINANT FACTOR VIIa (rFVIIa)", color: C.teal, x: 0.25, y: 3.55, w: 3.0, h: 1.9, items: ["Rescue agent — refractory coagulopathic hemorrhage", "pH > 7.2 & Temp > 33°C required for efficacy", "Dose: 90–120 μg/kg IV bolus", "NOT routinely recommended (↑ thrombotic risk)"] }, { title: "PROTHROMBIN COMPLEX\nCONCENTRATE (PCC)", color: C.crimson, x: 3.55, y: 3.55, w: 3.0, h: 1.9, items: ["Contains Factors II, VII, IX, X", "Reversal of warfarin anticoagulation", "25–50 units/kg IV rapid infusion", "Increasingly used in MTP for factor replacement"] }, { title: "VASOPRESSORS", color: C.gold, x: 6.8, y: 3.55, w: 2.95, h: 1.9, items: ["Noradrenaline: first-line for vasodilatory shock", "Vasopressin: adjunct in catecholamine-resistant shock", "Avoid before hemorrhage control — ↑ uncontrolled bleeding", "Target MAP ≥ 50–65 mmHg (no TBI)"] }, ]; adjuncts.forEach(({ title, color, x, y, w, h, items }) => { sl.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color: C.darkNav }, line: { color, width: 1.5 } }); sl.addShape(pres.ShapeType.rect, { x, y, w, h: 0.38, fill: { color } }); sl.addText(title, { x, y, w, h: 0.38, fontSize: 10, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(items.map((t, i) => ({ text: t, options: { bullet: true, color: C.lightGray, fontSize: 9, fontFace: "Calibri", breakLine: i < items.length - 1 } })), { x: x + 0.1, y: y + 0.42, w: w - 0.2, h: h - 0.46, valign: "top", margin: 2 }); }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 9 — COMPLICATIONS // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.offWhite); titleBar(sl, "Complications of Massive Transfusion", "Henry's Clinical Diagnosis · Rosen's EM · Morgan & Mikhail · Tietz Lab Medicine"); const comps = [ { title: "HYPOTHERMIA", color: C.steelBlue, items: ["Stored blood temp 1–6°C", "↓ coag factor activity (pH↓)", "Use: blood warmers, forced-air warming blankets, warm IV fluids", "Target: core temp > 36°C"] }, { title: "COAGULOPATHY / DIC", color: C.crimson, items: ["Dilution of factors & platelets", "Consumptive in trauma/DIC", "Monitor PT, aPTT, fibrinogen, TEG/ROTEM", "Replace: FFP, cryo, plt"] }, { title: "METABOLIC ACIDOSIS", color: C.orange, items: ["Citrate → bicarbonate (liver)", "Overwhelmed in hepatic failure → net acidosis", "DO NOT give NaHCO₃ empirically", "Optimize O₂ delivery + ventilation"] }, { title: "HYPOCALCEMIA", color: C.teal, items: ["Citrate chelation of Ca²⁺", "Each unit pRBC reduces iCa ~0.04 mmol/L", "Monitor: check iCa every 5–10 units", "Treat: CaCl₂ 1 g IV"] }, { title: "TACO", color: C.panelBg, items: ["Transfusion-Associated Circulatory Overload", "SpO₂↓, hypertension, pulmonary edema", "Risk: rapid infusion, cardiac dysfunction", "Treat: diuresis, slow/stop transfusion"] }, { title: "TRALI", color: "5D4037", items: ["Transfusion-Related Acute Lung Injury", "Anti-HLA / anti-HNA antibodies", "Onset: within 6 h of transfusion", "Hypoxia + bilateral infiltrates (non-cardiac)"] }, ]; comps.forEach(({ title, color, items }, i) => { const col = i % 3; const row = Math.floor(i / 3); const x = 0.25 + col * 3.22; const y = 1.25 + row * 2.05; sl.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h: 1.9, fill: { color: C.white }, line: { color, width: 2 } }); sl.addShape(pres.ShapeType.rect, { x, y, w: 3.1, h: 0.38, fill: { color } }); sl.addText(title, { x, y, w: 3.1, h: 0.38, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(items.map((t, idx) => ({ text: t, options: { bullet: true, color: "222222", fontSize: 9.5, fontFace: "Calibri", breakLine: idx < items.length - 1 } })), { x: x + 0.1, y: y + 0.42, w: 2.9, h: 1.42, valign: "top", margin: 2 }); }); // Electrolytes note sl.addShape(pres.ShapeType.rect, { x: 0.25, y: 5.1, w: 9.5, h: 0.38, fill: { color: C.darkNav } }); sl.addText("Also monitor: Hyperkalemia (stored blood K⁺ leakage) · Hypomagnesemia · Metabolic alkalosis (late — citrate → HCO₃⁻) · Thrombocytopenia · Haemolytic reactions", { x: 0.3, y: 5.1, w: 9.4, h: 0.38, fontSize: 9.5, color: C.gold, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 10 — ANESTHESIA MANAGEMENT CHECKLIST // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.darkBg); titleBar(sl, "Anesthesia Management Checklist — Intraoperative MTP", "Miller's Anesthesia 10e · Morgan & Mikhail 7e · Barash 9e"); const phases = [ { label: "PHASE 1\nPREPARATION", color: C.steelBlue, x: 0.2, y: 1.2, w: 2.35, h: 4.2, steps: ["Large-bore IV access (×2, ≥16G)", "Arterial line (radial/femoral)", "Central venous access (consider)", "Blood warmer ready (Level 1 / Belmont)", "Activate MTP with blood bank", "Type & screen / uncrossmatched O-neg RBC", "Pre-warm patient (forced air)", "Notify ICU team"] }, { label: "PHASE 2\nINDUCTION", color: C.crimson, x: 2.65, y: 1.2, w: 2.35, h: 4.2, steps: ["RSI if full stomach / airway compromise", "Ketamine preferred (↑ SVR, bronchodilation)", "Avoid propofol (vasodilatation)", "Etomidate if haemodynamic instability", "Succinylcholine or rocuronium + sugammadex", "Video laryngoscopy available", "Maintain C-spine precautions in trauma", "Target MAP ≥ 50 mmHg (no TBI)"] }, { label: "PHASE 3\nMAINTENANCE", color: C.orange, x: 5.1, y: 1.2, w: 2.35, h: 4.2, steps: ["Low-dose volatile + opioid or TIVA", "Monitor: temp (probe), SpO₂, EtCO₂, iCa", "iCa check per 5 units pRBC", "TEG/ROTEM goal-directed transfusion", "Transfuse 1:1:1 until hemorrhage controlled", "TXA 1g IV within 3h of onset", "Vasopressors PRN — noradrenaline first", "Permissive hypotension (no TBI)"] }, { label: "PHASE 4\nHANDOVER/ICU", color: C.teal, x: 7.45, y: 1.2, w: 2.35, h: 4.2, steps: ["Reverse coagulopathy before closure", "Target: plt > 50, fibrinogen > 2 g/L", "Correction of acidosis + temp > 36°C", "Document: total blood products, labs", "SBAR handover to ICU/PACU team", "Continue warming — hypothermia high risk", "Arrange: repeat labs at 1h post-op", "ICU admission criteria if MTP activated"] }, ]; phases.forEach(({ label, color, x, y, w, h, steps }) => { sl.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color: C.darkNav }, line: { color, width: 2 } }); sl.addShape(pres.ShapeType.rect, { x, y, w, h: 0.52, fill: { color } }); sl.addText(label, { x, y, w, h: 0.52, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(steps.map((t, i) => ({ text: t, options: { bullet: { code: "25CF", color }, color: C.lightGray, fontSize: 9, fontFace: "Calibri", breakLine: i < steps.length - 1 } })), { x: x + 0.1, y: y + 0.56, w: w - 0.2, h: h - 0.6, valign: "top", margin: 2 }); }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 11 — LABORATORY TARGETS // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.offWhite); titleBar(sl, "Laboratory Targets During MTP", "Henry's · Miller's · Barash · Goldman-Cecil Medicine"); const labs = [ ["PARAMETER", "ACTION THRESHOLD", "TARGET", "PRODUCT", C.darkNav], ["Hb / Haematocrit", "Hb < 7 g/dL (< 10 in cardiac)", "Hb 7–9 g/dL", "pRBC", C.crimson], ["Platelet count", "< 50 × 10⁹/L (< 100 in CNS)", "> 50–100 × 10⁹/L", "Platelets", C.teal], ["PT / INR", "INR > 1.5", "INR < 1.5", "FFP", C.steelBlue], ["aPTT", "> 1.5× upper normal", "< 45 sec", "FFP", C.steelBlue], ["Fibrinogen", "< 1.5–2 g/L", "> 2 g/L", "Cryoprecipitate", C.orange], ["Ionized Ca²⁺", "< 1.1 mmol/L", "> 1.1 mmol/L", "CaCl₂ 1 g IV", C.gold], ["Temp (core)", "< 35°C", "> 36°C", "Warming measures", C.purple || "7D3C98"], ["pH / BE", "pH < 7.2 / BE < -6", "pH > 7.3", "Optimize O₂ delivery", C.panelBg], ["TEG — MA", "MA < 50 mm", "> 55 mm", "Platelets ± rFVIIa", "5D4037"], ]; const colWidths = [2.3, 2.2, 2.2, 1.9, 1.15]; // ignore last (color) labs.forEach((row, ri) => { row.slice(0, 4).forEach((cell, ci) => { const x = 0.25 + [0, 2.35, 4.6, 6.85, 8.8][ci]; const y = 1.25 + ri * 0.38; const isHeader = ri === 0; sl.addShape(pres.ShapeType.rect, { x, y, w: colWidths[ci], h: 0.38, fill: { color: isHeader ? C.darkNav : (ri % 2 === 0 ? "F0F0F0" : C.white) }, line: { color: "CCCCCC", width: 0.5 } }); sl.addText(cell, { x: x + 0.05, y, w: colWidths[ci] - 0.1, h: 0.38, fontSize: isHeader ? 10 : 9.5, bold: isHeader, color: isHeader ? C.white : (ci === 0 ? "111111" : "222222"), valign: "middle", fontFace: "Calibri", margin: 0 }); }); // Color dot in last column if (ri > 0) { sl.addShape(pres.ShapeType.ellipse, { x: 9.0, y: 1.25 + ri * 0.38 + 0.09, w: 0.2, h: 0.2, fill: { color: row[4] } }); } }); } // ══════════════════════════════════════════════════════════════════════════════ // SLIDE 12 — SUMMARY / KEY MESSAGES // ══════════════════════════════════════════════════════════════════════════════ { const sl = pres.addSlide(); bg(sl, C.darkBg); sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.crimson } }); sl.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.85, fill: { color: C.darkNav } }); sl.addText("KEY TAKEAWAYS", { x: 0.25, y: 0.0, w: 9.5, h: 0.85, fontSize: 28, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", charSpacing: 3, margin: 0 }); const messages = [ { num: "1", text: "Activate MTP EARLY — do not wait for labs. Use clinical triggers: ≥3 pRBC/h or ABC score ≥ 2.", color: C.crimson }, { num: "2", text: "Transfuse 1:1:1 (pRBC:FFP:Platelets) — PROPPR trial evidence; consider LTOWB where available.", color: C.steelBlue }, { num: "3", text: "Damage Control Resuscitation: permissive hypotension (SBP 80–90) + minimize crystalloid + early blood products.", color: C.orange }, { num: "4", text: "TXA within 3 hours of injury — reduces mortality in CRASH-2 and MATTERS; harmful if delayed.", color: C.teal }, { num: "5", text: "Break the lethal triad: keep patient WARM (>36°C), correct ACIDOSIS, and replace coagulation factors.", color: C.gold }, { num: "6", text: "Use TEG/ROTEM for goal-directed therapy — superior to conventional labs in guiding blood product choice.", color: "7D3C98" }, ]; messages.forEach(({ num, text, color }, i) => { const row = Math.floor(i / 2); const col = i % 2; const x = 0.3 + col * 4.88; const y = 1.0 + row * 1.45; sl.addShape(pres.ShapeType.rect, { x, y, w: 4.6, h: 1.28, fill: { color: C.darkNav }, line: { color, width: 1.5 } }); sl.addShape(pres.ShapeType.rect, { x, y, w: 0.5, h: 1.28, fill: { color } }); sl.addText(num, { x, y, w: 0.5, h: 1.28, fontSize: 22, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); sl.addText(text, { x: x + 0.58, y: y + 0.1, w: 3.95, h: 1.08, fontSize: 11, color: C.lightGray, valign: "middle", fontFace: "Calibri", margin: 2 }); }); sl.addShape(pres.ShapeType.rect, { x: 0, y: 5.25, w: 10, h: 0.375, fill: { color: C.panelBg } }); sl.addText("Sources: Morgan & Mikhail 7e · Miller's Anesthesia 10e · Barash 9e · Sabiston · Rosen's · Henry's · PROPPR (JAMA 2015) · CRASH-2 · MATTERS", { x: 0.2, y: 5.25, w: 9.6, h: 0.375, fontSize: 9, color: "AAAAAA", align: "center", valign: "middle", fontFace: "Calibri", margin: 0 }); } // ══════════════════════════════════════════════════════════════════════════════ // WRITE FILE // ══════════════════════════════════════════════════════════════════════════════ pres.writeFile({ fileName: "/home/daytona/workspace/mtp-anesthesia-ppt/MTP_Anesthesia_MD.pptx" }) .then(() => console.log("SUCCESS: MTP_Anesthesia_MD.pptx created")) .catch(err => { console.error("ERROR:", err); process.exit(1); });