Which section should I prepare in full first?

cardiac surgery massive bleeding

2024 EACTS EACTAIC patient blood management adult cardiac surgery guideline bleeding

~/

PMID: 39385500

https://pubmed.ncbi.nlm.nih.gov/39385500/

~/attachments/fe8d6999-83dc-4be4-ad06-0f225cf637c4

mkdir -p "/tmp/workspace/mortality-case-hemant-sole/src" "/tmp/workspace/mortality-case-hemant-sole/output" && cat > "/tmp/workspace/mortality-case-hemant-sole/src/create_deck.py" <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.enum.shapes import MSO_SHAPE from pptx.dml.color import RGBColor from pptx.enum.dml import MSO_THEME_COLOR from PIL import Image import os OUT='/tmp/workspace/mortality-case-hemant-sole/output/Hemant_Sole_Mortality_Case_Discussion.pptx' AS='/tmp/workspace/attachments/fe8d6999-83dc-4be4-ad06-0f225cf637c4' imgs={ 'adm':os.path.join(AS,'1 ipd admission details.jpeg'), 'initial':os.path.join(AS,'1.1 pre op & stabilization.jpeg'), 'stab1':os.path.join(AS,'2 pre op & stabilization.jpeg'), 'stab2':os.path.join(AS,'3 pre op & stabilization.jpeg'), 'stab3':os.path.join(AS,'4 pre op & stabilization.jpeg'), 'stab4':os.path.join(AS,'5. pre op & stabilization.jpeg'), 'ot':os.path.join(AS,'7 OT to intro op.jpeg'), 'opnote':os.path.join(AS,'7.1.jpeg'), 'abg':os.path.join(AS,'9 ABG intraop.jpeg'), } prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) blank=prs.slide_layouts[6] NAVY=RGBColor(20,46,70); TEAL=RGBColor(27,108,123); RED=RGBColor(157,45,45); GOLD=RGBColor(193,139,44); LIGHT=RGBColor(243,246,248); GRAY=RGBColor(86,98,108); DARK=RGBColor(35,40,45) def bg(s, title, subtitle=None, section=False): s.background.fill.solid(); s.background.fill.fore_color.rgb=RGBColor(255,255,255) band=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,0,prs.slide_width,Inches(.52)); band.fill.solid(); band.fill.fore_color.rgb=NAVY; band.line.fill.background() tx=s.shapes.add_textbox(Inches(.48),Inches(.67),Inches(12.3),Inches(.52)); tf=tx.text_frame; tf.clear(); tf.margin_left=tf.margin_right=0 p=tf.paragraphs[0]; p.text=title; p.font.name='Aptos Display'; p.font.size=Pt(27); p.font.bold=True; p.font.color.rgb=NAVY if subtitle: st=s.shapes.add_textbox(Inches(.5),Inches(1.2),Inches(12),Inches(.3)); t=st.text_frame; t.clear(); p=t.paragraphs[0]; p.text=subtitle; p.font.name='Aptos'; p.font.size=Pt(11); p.font.color.rgb=GRAY footer=s.shapes.add_textbox(Inches(.5),Inches(7.13),Inches(12.2),Inches(.2)); tf=footer.text_frame; tf.clear(); p=tf.paragraphs[0]; p.text='Mortality case discussion | Documented record summary | Verify against original EMR, anaesthesia chart, ICU chart and death certificate'; p.font.size=Pt(8); p.font.color.rgb=GRAY; p.alignment=PP_ALIGN.RIGHT def text(s,x,y,w,h,content,size=18,color=DARK,bold=False,bullets=False): t=s.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h)); tf=t.text_frame; tf.clear(); tf.word_wrap=True; tf.margin_left=Inches(.05);tf.margin_right=Inches(.04);tf.margin_top=Inches(.03) lines=content if isinstance(content,list) else [content] for i,line in enumerate(lines): p=tf.paragraphs[0] if i==0 else tf.add_paragraph() p.text=line; p.font.name='Aptos';p.font.size=Pt(size);p.font.color.rgb=color;p.font.bold=bold if bullets: p.level=0; p.text='• '+line p.space_after=Pt(5) return t def box(s,x,y,w,h,heading,lines,accent=TEAL): sh=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE, Inches(x),Inches(y),Inches(w),Inches(h)); sh.fill.solid();sh.fill.fore_color.rgb=LIGHT;sh.line.color.rgb=RGBColor(215,224,229) accentbar=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(x),Inches(y),Inches(.09),Inches(h));accentbar.fill.solid();accentbar.fill.fore_color.rgb=accent;accentbar.line.fill.background() text(s,x+.22,y+.13,w-.35,.32,heading,15,accent,True) text(s,x+.22,y+.52,w-.35,h-.6,lines,13,DARK,False,True) def pic(s,path,x,y,w,h): im=Image.open(path); iw,ih=im.size; ar=iw/ih; target=w/h if ar>target: # crop width crop_w=int(ih*target); left=(iw-crop_w)//2; im=im.crop((left,0,left+crop_w,ih)) else: crop_h=int(iw/target); top=(ih-crop_h)//2; im=im.crop((0,top,iw,top+crop_h)) tmp='/tmp/workspace/mortality-case-hemant-sole/src/_tmp.jpg'; im.save(tmp,quality=90) s.shapes.add_picture(tmp, Inches(x), Inches(y), width=Inches(w),height=Inches(h)) # 1 s=prs.slides.add_slide(blank); s.background.fill.solid();s.background.fill.fore_color.rgb=NAVY text(s,.7,.75,11.7,.7,'MORTALITY CASE DISCUSSION',32,RGBColor(255,255,255),True) text(s,.72,1.58,11.6,.45,'Mr Hemant Ambadas Sole | 35-year-old male',23,RGBColor(225,236,242),True) text(s,.75,2.15,11,.42,'Index admission: 24 August 2026 | Cardiac surgery: 15 September 2026 | Death: reported 16 September 2026',16,RGBColor(225,236,242)) text(s,.75,3.05,11.5,1.3,['Purpose: factual reconstruction of the documented course, perioperative events, and system-learning questions.','This deck does not determine cause of death or assign individual responsibility.'],18,RGBColor(255,255,255)) text(s,.75,6.72,11.7,.3,'Confidential quality-improvement material. Remove patient identifiers before external circulation.',11,RGBColor(203,220,230)) # 2 case identity s=prs.slides.add_slide(blank); bg(s,'1. Case identity and record scope') box(s,.55,1.6,3.9,4.9,'Patient / admission',['Name: Hemant Ambadas Sole','Age/sex: 35 years / male','Admission record: General Medicine, MICU-1','Admission date/time printed: 24 Aug 2026, 15:44','Casualty presentation noted at 14:30'],TEAL) box(s,4.72,1.6,3.9,4.9,'Key documented diagnoses',['CHD with small perimembranous VSD (6 mm), left-to-right shunt','Severe aortic regurgitation; mild TR and mild pulmonary hypertension','CKD on regular haemodialysis','Pericardial effusion'],GOLD) box(s,8.9,1.6,3.85,4.9,'Important documentation checks',['Notes contain a diary header from 2023, but clinical entries state 2026.','Death date differs: user reports 16 Sep; handwritten OT-page note appears to record declaration at 01:40 after 15 Sep surgery.','Reconcile with official death certificate and ICU/anaesthesia records.'],RED) # 3 admission s=prs.slides.add_slide(blank); bg(s,'2. Presentation at admission: severe multisystem decompensation','From handwritten casualty/initial notes dated 24 August 2026') box(s,.55,1.55,4.0,4.95,'Symptoms / signs',['Severe breathlessness and chest pain','Severe bilateral pedal oedema','Drowsy but obeying commands','Marked oliguria for 10-15 days','BP 185/60 mmHg; pulse 101/min','SpO2 75% on room air; bilateral crepitations; pansystolic murmur'],RED) box(s,4.7,1.55,3.7,4.95,'Initial investigations',['ABG recorded: pH 6.9, HCO3 3.7, K+ 6.81','Hb 6.6 g/dL; TLC 11.5; platelets 298','Creatinine 15.9 mg/dL; urea noted ~280 mg/dL','Immediate clinical picture: pulmonary congestion, renal failure with severe acidemia/hyperkalaemia, anaemia, and pericardial effusion'],GOLD) pic(s,imgs['initial'],8.65,1.55,3.95,4.95); text(s,8.65,6.55,3.95,.25,'Source: initial handwritten clinical note',9,GRAY) # 4 stabilization s=prs.slides.add_slide(blank); bg(s,'3. Early stabilization and renal support','24 August to early September 2026, as recorded') box(s,.55,1.55,3.9,4.95,'Immediate actions',['BiPAP initiated; later documentation: FiO2 80%, SpO2 improved to 99%, RR 22/min','Haemodialysis catheter and Foley catheter inserted','Nephrology opinion: urgent haemodialysis advised','1 unit PRBC noted before/during HD','Inj. Cordarone 5 mL/h documented'],TEAL) box(s,4.7,1.55,3.9,4.95,'Ongoing management',['Antimicrobial and supportive medications recorded, including ceftriaxone, pantoprazole, albumin, sodium bicarbonate and sevelamer','Heparin 5000 IU noted, with “no IVF” recorded','Noradrenaline 4 mL/h started on 3 Sep','HD continued on alternate days','Urine output improved from anuria to 10-15 mL/h, then 15-20 mL/h and later 50-60 mL/h'],GOLD) pic(s,imgs['stab1'],8.85,1.55,3.55,4.95); text(s,8.85,6.55,3.55,.25,'Source: stabilization note',9,GRAY) # 5 evolution s=prs.slides.add_slide(blank); bg(s,'4. Clinical evolution before surgery','Documented improvement in oxygenation and urine output, with continued high baseline risk') box(s,.55,1.55,4.05,4.95,'Physiological trend',['24-26 Aug: no urine documented; BiPAP requirement persisted','26-28 Aug: urine output stated as 10-15 mL/h','30 Aug-1 Sep: on 2 L oxygen; urine 15-20 mL/h; alternate-day HD continued','1-2 Sep: room air; SpO2 94%; BP 130/50; HR 86/min','3-4 Sep: on minimal oxygen; SpO2 95-97%; urine ~20 mL/h'],TEAL) box(s,4.8,1.55,3.95,4.95,'Imaging / echocardiography',['USG: bilateral small kidneys, thinned parenchyma and reduced corticomedullary differentiation, consistent with chronic kidney disease','Pericardial effusion recorded as 2.7 cm in one note','31 Aug 2D echo: severe AR, large VSD, mild pericardial effusion, dilated LA/LV, EF 44%, congested IVC','Surgery was scheduled for 15 Sep after conservative/HD management'],GOLD) pic(s,imgs['stab3'],9.0,1.55,3.2,4.95); text(s,9.0,6.55,3.2,.25,'Source: preoperative progress note',9,GRAY) # 6 risk framing s=prs.slides.add_slide(blank); bg(s,'5. Preoperative risk framing','Risk factors evident in the supplied record') box(s,.55,1.55,3.9,4.95,'Cardiac / surgical',['Congenital VSD with severe AR requiring combined VSD closure and aortic valve replacement','Pericardial effusion and anticipated pericardial adhesions','LV/LA dilatation; EF documented 44%','Pulmonary hypertension and valvular disease'],RED) box(s,4.72,1.55,3.9,4.95,'Non-cardiac / haemostatic',['End-stage kidney disease on regular HD, with oliguria','Profound initial metabolic acidosis and hyperkalaemia','Severe anaemia at presentation','Critical illness with respiratory failure and vasopressor requirement earlier in admission','Potential platelet dysfunction/coagulopathy risk in renal failure and CPB setting'],GOLD) box(s,8.9,1.55,3.85,4.95,'Discussion prompts',['Was preoperative Hb, platelet function and coagulation profile documented immediately before OT?','Was a patient-specific blood conservation and massive-bleeding plan documented?','Were dialysis timing, volume status, potassium and acid-base targets recorded before bypass?','Were patient and family counseled about the extreme perioperative risk?'],TEAL) # 7 procedure s=prs.slides.add_slide(blank); bg(s,'6. Operation performed: 15 September 2026','Source: formal operative note') box(s,.55,1.55,4.05,4.95,'Procedure',['Median sternotomy','Pericardial adhesiolysis and pericardial cradle','Aorto-bicaval cannulation and cardiopulmonary bypass','VSD closure with SFD patch','Aortic valve replacement with On-X 21 mm mechanical valve','Rewarming and weaning from CPB'],TEAL) box(s,4.85,1.55,3.8,4.95,'Operative timing / context',['Start: 1:10 PM','End: 11:30 PM','General anaesthesia; supine position','Surgeon: Dr Vidyut Kumar (as printed)','Diagnosis stated: CHD, small perimembranous VSD with L-to-R shunt, severe AR, mild TR/mild PH, CKD on regular HD'],GOLD) pic(s,imgs['opnote'],8.9,1.55,3.45,4.95); text(s,8.9,6.55,3.45,.25,'Source: operative note',9,GRAY) # 8 intraop findings s=prs.slides.add_slide(blank); bg(s,'7. Intraoperative findings and major event','Quoted/paraphrased from operative note and OT handwritten record') box(s,.55,1.55,4.1,4.95,'Anatomical findings',['Large pericardial effusion with septations','Dense pericardial adhesions','Small subaortic VSD','Severe AR','Aortic valve incompetent; right coronary cusp severely prolapsed with perforated leaflet'],TEAL) box(s,4.9,1.55,3.75,4.95,'Haemorrhagic event',['Following protamine, operative note records “generalized diffuse bleeding from all the raw surface of heart despite standard haemostatic measure.”','No focal bleeding source/clot was documented in OT handwritten note.','Handwritten note records fibrinogen and blood products given, and persistent bleeding despite factor VIII.','Patient transferred with high inotropic support and poor haemodynamics.'],RED) pic(s,imgs['ot'],8.9,1.55,3.45,4.95); text(s,8.9,6.55,3.45,.25,'Source: OT/intraoperative note',9,GRAY) # 9 blood abg s=prs.slides.add_slide(blank); bg(s,'8. Intraoperative resuscitation and available laboratory record','Values below are transcribed only where legible; validate against anaesthesia machine/ABG printouts') box(s,.55,1.55,4.15,4.95,'Blood component therapy noted',['OT note: 40 cryoprecipitate, 30 PCV, 40 RDP, 10 SDP and 60 FFP units/products recorded','Fibrinogen administered','Protamine given, with a double dose noted in handwritten OT note','Factor VIII reportedly administered without response','The formal operative note confirms persistent diffuse bleeding despite standard haemostatic measures'],RED) box(s,4.95,1.55,3.55,4.95,'ABG image interpretation',['The supplied collage shows serial intraoperative ABG printouts.','Legible trends include marked anaemia in several samples, with variable acidosis/base deficit and electrolyte abnormalities.','This deck intentionally does not publish exact serial ABG values because image legibility and sampling times cannot be reliably reconciled.','Present the original machine printouts at the meeting.'],GOLD) pic(s,imgs['abg'],8.75,1.55,3.75,4.95); text(s,8.75,6.55,3.75,.25,'Source: intraoperative ABG photo collage',9,GRAY) # 10 death s=prs.slides.add_slide(blank); bg(s,'9. Immediate postoperative course and outcome','There is a date/time discrepancy requiring formal reconciliation') box(s,.55,1.55,4.0,4.95,'Transfer from OT',['Operative note: shift to CRU with high inotropic support and poor haemodynamics','Handwritten OT note: no response to bleeding interventions; shifted to ICU with profuse bleeding from raw heart surfaces','Documentation suggests a critical postoperative haemorrhagic and haemodynamic state at ICU transfer'],RED) box(s,4.8,1.55,3.85,4.95,'Reported outcome',['User-reported declared date: 16 September 2026','Handwritten OT-to-ICU note: “declared at 1:40 AM” following surgery on 15 September, but the associated printed diary date is unreliable','Official declaration date/time, terminal event and certified cause(s) of death must be taken from the death certificate and ICU resuscitation record'],GOLD) box(s,8.9,1.55,3.85,4.95,'Provisional event sequence',['High-risk dialysis-dependent patient underwent complex congenital/valve surgery','CPB and repair completed; patient weaned from bypass','Generalized, refractory diffuse surgical-surface bleeding after protamine','Massive blood-component and haemostatic therapy documented','ICU transfer on high inotropes/poor haemodynamics followed by death'],TEAL) # 11 analysis s=prs.slides.add_slide(blank); bg(s,'10. Mortality-review analysis: contributory factors','Hypotheses for review only. They require triangulation with complete source records.') box(s,.55,1.55,3.9,4.95,'Patient factors',['Advanced chronic kidney disease and dialysis dependence','Initial profound acidosis/hyperkalaemia and respiratory failure','Severe anaemia at presentation','Complex structural heart disease with LV dysfunction, PH and pericardial disease'],RED) box(s,4.72,1.55,3.9,4.95,'Procedure-related factors',['Long, complex combined operation with CPB','Dense adhesions and raw surgical surfaces','Pericardial effusion/septations','Post-protamine refractory generalized bleeding','Potential multifactorial CPB-associated coagulopathy and renal-related platelet dysfunction'],GOLD) box(s,8.9,1.55,3.85,4.95,'Outcome mechanism to verify',['Immediate cause may have involved uncontrolled postoperative/intraoperative haemorrhage and shock.','Contributing mechanisms could include surgical bleeding, CPB-related coagulopathy, dilutional coagulopathy, hypofibrinogenaemia, platelet dysfunction, heparin-protamine imbalance, and renal failure.','Do not finalize causation without records, lab results and multidisciplinary review.'],TEAL) # 12 actions s=prs.slides.add_slide(blank); bg(s,'11. Learning points and actions for the M&M meeting','Frame actions at system level, not as retrospective attribution') box(s,.55,1.55,4.0,4.95,'Records to obtain before final review',['Full ICU flow sheets, nursing notes and code sheet','Anaesthesia record: ACTs, heparin/protamine doses, bypass times, temperature, fluid balance, transfusion chronology','Serial CBC, PT/INR, aPTT, fibrinogen, ionized calcium, ABG/lactate and viscoelastic testing, if done','Blood bank issue/return record and massive-transfusion activation timeline','Death certificate / official death declaration'],TEAL) box(s,4.8,1.55,3.85,4.95,'Questions for team review',['Was bleeding managed through a time-stamped, goal-directed algorithm using point-of-care coagulation testing where available?','Were thresholds/escalation points for re-exploration, component therapy and factor concentrates explicit?','Was a pre-CPB haemostasis plan adapted to dialysis dependence, anaemia and complex surgery?','Were inter-team communications and family updates documented during the critical event?'],GOLD) box(s,8.9,1.55,3.85,4.95,'Evidence context',['Contemporary cardiac-surgery blood-management guidance supports multidisciplinary planning, prevention of coagulopathy, and algorithmic/point-of-care guided haemostasis where available.','This is a practice-improvement reference, not evidence that a particular action was omitted in this case.','Reference: 2024 EACTS/EACTAIC PBM guideline, PMID 39385500.'],RED) # 13 chronology s=prs.slides.add_slide(blank); bg(s,'12. One-slide chronology for oral presentation') items=[('24 Aug','Casualty presentation: hypoxaemia, pulmonary congestion, oliguria, severe metabolic derangement, anaemia; BiPAP and urgent HD pathway.'),('24 Aug-4 Sep','HD, respiratory and vasopressor support; gradual improvement in oxygenation/urine output; CKD/pericardial effusion/structural heart disease defined.'),('31 Aug-14 Sep','Echo showed severe AR, VSD, EF 44% and dilated chambers; conservative and HD management pending surgery.'),('15 Sep','VSD closure + On-X 21 mm AVR. Dense adhesions, large septated pericardial effusion, abnormal aortic valve. Post-protamine diffuse refractory bleeding.'),('15-16 Sep','High-inotrope ICU/CRU transfer with poor haemodynamics and ongoing bleeding. Death subsequently declared; exact official time/date to be verified.')] for i,(d,desc) in enumerate(items): y=1.5+i*1.05 circ=s.shapes.add_shape(MSO_SHAPE.OVAL,Inches(.65),Inches(y),Inches(.78),Inches(.53)); circ.fill.solid();circ.fill.fore_color.rgb=TEAL if i<3 else RED;circ.line.fill.background(); text(s,.7,y+.11,.68,.2,d,10,RGBColor(255,255,255),True) text(s,1.65,y-.02,10.75,.65,desc,17,DARK) if i<4: line=s.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(1.02),Inches(y+.54),Inches(.06),Inches(.52));line.fill.solid();line.fill.fore_color.rgb=RGBColor(198,212,220);line.line.fill.background() text(s,.65,6.82,11.9,.2,'Closing statement: This death followed a high-risk course with catastrophic diffuse bleeding after complex cardiac surgery. The formal review should focus on a verified timeline, cause-of-death documentation, and system learning.',11,RED,True) prs.save(OUT) print(OUT) PY python "/tmp/workspace/mortality-case-hemant-sole/src/create_deck.py" python - <<'PY' from pptx import Presentation p='/tmp/workspace/mortality-case-hemant-sole/output/Hemant_Sole_Mortality_Case_Discussion.pptx' prs=Presentation(p) print('slides',len(prs.slides),'size',__import__('os').path.getsize(p)) for i,s in enumerate(prs.slides,1): print(i, next((sh.text.split('\n')[0] for sh in s.shapes if getattr(sh,'has_text_frame',False) and sh.text.strip()),'')) PY