Cookbook 361: Offline Clinical Surgical Critical Care Abdominal Compartment Syndrome WSACS & APP Engine

"""
Cookbook 361: Offline Surgical Critical Care Abdominal Compartment Syndrome WSACS & APP Engine
OpenPHR Clinical AI Working Group (https://openphr.org)
"""

import math
import numpy as np
import pandas as pd
from typing import Dict, List, Tuple, Optional
from dataclasses import dataclass

@dataclass
class ACSTelemetry:
    patient_id: str
    age_years: float = 46.0
    patient_weight_kg: float = 82.0
    # Pressure Telemetry
    bladder_iap_mmhg: float = 23.5 # >= 21-25 mmHg = Grade III IAH
    instillation_volume_ml: float = 25.0 # Must be <= 25 mL per WSACS Kron standard
    mean_arterial_pressure_mmhg: float = 72.0 # APP = 72 - 23.5 = 48.5 mmHg (< 60 mmHg!)
    # Ventilatory & Respiratory Telemetry
    pao2_fio2_ratio: float = 175.0 # <= 200 = Severe pulmonary compromise
    peak_inspiratory_pressure_cmh2o: float = 38.0 # High intrathoracic transmission
    is_mechanically_ventilated: bool = True
    # Renal & Perfusion Telemetry
    urine_output_ml_kg_hr: float = 0.22 # < 0.5 mL/kg/h = Oliguria (Renal Failure)
    serum_creatinine_mg_dl: float = 2.1
    # Fluid Balance & Interventions
    net_fluid_balance_24h_liters: float = 8.4 # Massive positive fluid resuscitation
    has_nasogastric_tube: bool = True
    has_percutaneous_drain: bool = False
    is_receiving_neuromuscular_blockade: bool = False

@dataclass
class ACSEvaluationReport:
    patient_id: str
    wsacs_iah_grade: str # "GRADE III INTRA-ABDOMINAL HYPERTENSION (21-25 mmHg)"
    abdominal_perfusion_pressure_mmhg: float # 48.5 mmHg
    acs_diagnosis_status: str # "CONFIRMED ABDOMINAL COMPARTMENT SYNDROME (ACS)"
    stepped_medical_orders: List[str]
    surgical_decompression_recommendation: str
    safety_sentinels: List[str]
    clinical_wsacs_east_directive: str

class AbdominalCompartmentDecisionEngine:
    """
    Offline clinical engine for WSACS IAH grading, Abdominal Perfusion Pressure (APP)
    optimization, stepped medical escalation, and emergent decompressive laparotomy gating.
    """

    def audit_transduction_quality(self, d: ACSTelemetry) -> Tuple[bool, List[str]]:
        sentinels = []
        is_valid = True

        if d.instillation_volume_ml > 25.0:
            is_valid = False
            sentinels.append(f"🚨 TRANSDUCTION ARTIFACT ERROR: Bladder instillation volume ({d.instillation_volume_ml:.0f} mL) exceeds WSACS 25 mL limit. High instillation volumes stretch the detrusor muscle, falsely overestimating IAP by 4-8 mmHg. Repeat transduction with strictly <= 20-25 mL sterile saline!")

        return is_valid, sentinels

    def stage_wsacs_iah(self, iap: float) -> Tuple[str, str]:
        if iap > 25.0:
            return "GRADE IV INTRA-ABDOMINAL HYPERTENSION (IAP > 25 mmHg)", "Extreme, life-threatening pressure; severe visceral hypoperfusion and cardiac collapse."
        elif 21.0 <= iap <= 25.0:
            return "GRADE III INTRA-ABDOMINAL HYPERTENSION (IAP 21 to 25 mmHg)", "Severe intra-abdominal hypertension; high risk of progression to full compartment syndrome."
        elif 16.0 <= iap <= 20.0:
            return "GRADE II INTRA-ABDOMINAL HYPERTENSION (IAP 16 to 20 mmHg)", "Moderate intra-abdominal hypertension; requires immediate medical escalation."
        elif 12.0 <= iap <= 15.0:
            return "GRADE I INTRA-ABDOMINAL HYPERTENSION (IAP 12 to 15 mmHg)", "Mild intra-abdominal hypertension; initiate baseline surveillance."
        else:
            return "NORMAL INTRA-ABDOMINAL PRESSURE (< 12 mmHg)", "Intra-abdominal pressure is within acceptable physiological limits."

    def calculate_app(self, d: ACSTelemetry) -> float:
        app = d.mean_arterial_pressure_mmhg - d.bladder_iap_mmhg
        return round(app, 1)

    def evaluate_acs(self, d: ACSTelemetry, iap: float, app: float) -> Tuple[str, List[str]]:
        failures = []

        # Renal Failure
        if d.urine_output_ml_kg_hr < 0.50 or d.serum_creatinine_mg_dl >= 2.0:
            failures.append(f"Oliguric Renal Failure (UO {d.urine_output_ml_kg_hr:.2f} mL/kg/h, Cr {d.serum_creatinine_mg_dl:.1f})")

        # Respiratory Failure
        if d.pao2_fio2_ratio <= 200.0 or d.peak_inspiratory_pressure_cmh2o >= 35.0:
            failures.append(f"Respiratory Failure (PaO2/FiO2 {d.pao2_fio2_ratio:.0f}, PIP {d.peak_inspiratory_pressure_cmh2o:.0f} cmH2O)")

        # Hemodynamic / Perfusion Failure
        if app < 60.0:
            failures.append(f"Visceral Hypoperfusion (APP {app:.1f} mmHg < 60 mmHg)")

        if iap > 20.0 and len(failures) >= 1:
            status = f"🚨 CONFIRMED ABDOMINAL COMPARTMENT SYNDROME (ACS) - Sustained IAP {iap:.1f} mmHg with {len(failures)} New Organ Failures: {'; '.join(failures)}."
        elif iap >= 12.0:
            status = f"Intra-Abdominal Hypertension without Fulminant ACS ({len(failures)} organ dysfunctions detected)."
        else:
            status = "No Abdominal Compartment Syndrome."

        return status, failures

    def generate_stepped_medical_plan(self, d: ACSTelemetry, iap: float, app: float) -> List[str]:
        orders = []

        orders.append("1. STEP 1 (EVACUATE INTRALUMINAL CONTENTS):")
        if not d.has_nasogastric_tube:
            orders.append("   • STAT Placement of Nasogastric/Orogastric Tube on low intermittent suction.")
        else:
            orders.append("   • Verify NG/OG tube patency; initiate rectal tube drainage and prokinetics (Metoclopramide 10mg IV q6h).")

        orders.append("2. STEP 2 (EVACUATE SPACE-OCCUPYING LESIONS):")
        orders.append("   • Perform bedside abdominal ultrasound/CT to assess for drainable ascites, retroperitoneal hematoma, or abscess; perform percutaneous catheter drainage (PCD) if fluid present.")

        orders.append("3. STEP 3 (IMPROVE ABDOMINAL WALL COMPLIANCE):")
        orders.append("   • Deep sedation and analgesia (fentanyl + midazolam/propofol); avoid patient-ventilator dyssynchrony.")
        if not d.is_receiving_neuromuscular_blockade and iap >= 16.0:
            orders.append("   • Initiate Trial of Neuromuscular Blockade (Cisatracurium bolus + continuous infusion) to reduce abdominal wall tension.")

        orders.append("4. STEP 4 (OPTIMIZE FLUID RESUSCITATION & PERFUSION):")
        orders.append(f"   • Target Abdominal Perfusion Pressure (APP) >= 60 mmHg (Current: {app:.1f} mmHg). Titrate Norepinephrine to maintain MAP >= {iap + 60.0:.0f} mmHg.")
        if d.net_fluid_balance_24h_liters > 3.0:
            orders.append("   • CEASE CRYSTALLOID RESUSCITATION. Initiate diuresis (Furosemide + 20% Albumin) or CRRT with net ultrafiltration to achieve negative fluid balance.")

        return orders

    def evaluate_surgical_decompression(self, d: ACSTelemetry, iap: float, app: float, has_acs: bool) -> Tuple[str, List[str]]:
        sentinels = []

        if iap > 25.0 or (has_acs and (app < 50.0 or d.urine_output_ml_kg_hr < 0.30)):
            surg_rec = "🚨 STAT EMERGENT DECOMPRESSIVE LAPAROTOMY MANDATED: Patient has refractory ACS with critical visceral hypoperfusion and multi-organ failure. Immediate surgical decompression with Open Abdomen Negative Pressure Wound Therapy (NPWT / ABThera) indicated."
            sentinels.append("🚨 REPERFUSION WASHOUT SHOCK HAZARD: Surgical release of abdominal fascia releases massive sequestered lactate, potassium, and acid metabolites into systemic circulation while mesenteric vasodilation causes sudden blood pooling. PRE-HYDRATE, PUSH 2 AMPS NaHCO3, AND TITRATE NOREPINEPHRINE BEFORE FASCIAL OPENING TO PREVENT FATAL ASYSTOLE!")
        elif has_acs:
            surg_rec = "URGENT SURGICAL CONSULTATION & DECOMPRESSION PREPARATION: Implement maximal medical escalation for 1-2 hours. If IAP remains > 20 mmHg or organ failure worsens, proceed immediately to decompressive laparotomy."
        else:
            surg_rec = "Surgical decompression not immediately indicated. Continue medical management and serial IAP q4h."

        return surg_rec, sentinels

    def evaluate_case(self, data: ACSTelemetry) -> ACSEvaluationReport:
        is_qc_valid, sentinels_qc = self.audit_transduction_quality(data)
        iap = data.bladder_iap_mmhg
        app = self.calculate_app(data)
        iah_stage, iah_desc = self.stage_wsacs_iah(iap)
        acs_status, failures = self.evaluate_acs(data, iap, app)
        has_acs = "CONFIRMED ABDOMINAL COMPARTMENT SYNDROME" in acs_status

        med_orders = self.generate_stepped_medical_plan(data, iap, app)
        surg_rec, sentinels_surg = self.evaluate_surgical_decompression(data, iap, app, has_acs)

        all_sentinels = sentinels_qc + sentinels_surg

        directives = []
        directives.append(f"STAGE: {iah_stage}.")
        directives.append(f"APP: {app:.1f} mmHg (Target >= 60).")
        directives.append(f"STATUS: {acs_status}.")
        directives.append(f"SURGERY: {surg_rec}.")

        return ACSEvaluationReport(
            patient_id=data.patient_id,
            wsacs_iah_grade=iah_stage,
            abdominal_perfusion_pressure_mmhg=app,
            acs_diagnosis_status=acs_status,
            stepped_medical_orders=med_orders,
            surgical_decompression_recommendation=surg_rec,
            safety_sentinels=all_sentinels,
            clinical_wsacs_east_directive=" ".join(directives)
        )

# Example Execution & Verification
if __name__ == "__main__":
    engine = AbdominalCompartmentDecisionEngine()

    print("=" * 80)
    print("OpenPHR Clinical Surgical ICU Abdominal Compartment Syndrome & APP Engine")
    print("=" * 80)

    # Test Case 1: 46-year-old male s/p exploratory laparotomy and massive transfusion for severe trauma.
    # Labs/Telemetry: Bladder IAP 23.5 mmHg (Grade III IAH), MAP 72 mmHg -> APP 48.5 mmHg (< 60!).
    # Respiratory: PaO2/FiO2 175, PIP 38 cmH2O. Renal: Oliguria 0.22 mL/kg/h, Cr 2.1 mg/dL.
    # Diagnosis: Confirmed Abdominal Compartment Syndrome (ACS) with dual organ failure!
    # Triage: 5-Step Medical Escalation + STAT Decompressive Laparotomy Gating!
    # Sentinel: Pre-decompression bicarb and pressors for Reperfusion Washout Shock!
    acs1 = ACSTelemetry(
        patient_id="SICU-ACS-8801",
        age_years=46.0,
        patient_weight_kg=82.0,
        bladder_iap_mmhg=23.5,
        instillation_volume_ml=25.0,
        mean_arterial_pressure_mmhg=72.0,
        pao2_fio2_ratio=175.0,
        peak_inspiratory_pressure_cmh2o=38.0,
        is_mechanically_ventilated=True,
        urine_output_ml_kg_hr=0.22,
        serum_creatinine_mg_dl=2.1,
        net_fluid_balance_24h_liters=8.4,
        has_nasogastric_tube=True,
        has_percutaneous_drain=False,
        is_receiving_neuromuscular_blockade=False
    )

    rep1 = engine.evaluate_case(acs1)

    print(f"\n[Patient {rep1.patient_id} - Surgical ICU ACS Assessment]")
    print(f"WSACS Staging: {rep1.wsacs_iah_grade}")
    print(f"Abdominal Perfusion Pressure (APP): {rep1.abdominal_perfusion_pressure_mmhg:.1f} mmHg (Target >= 60 mmHg)")
    print(f"ACS Status:\n  {rep1.acs_diagnosis_status}")
    print("\nStepped Medical Management Orders:")
    for o in rep1.stepped_medical_orders:
        print(f"  {o}")
    print(f"\nSurgical Decompression Directive:\n  {rep1.surgical_decompression_recommendation}")
    if rep1.safety_sentinels:
        print("\nSafety Sentinels:")
        for s in rep1.safety_sentinels:
            print(f"  🚨 {s}")
    print(f"\nWSACS / EAST Consensus Directive:\n{rep1.clinical_wsacs_east_directive}")