MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C28063.34D09E00" This document is a Web archive file. If you are seeing this message, this means your browser or editor doesn't support Web archive files. For more information on the Web archive format, go to http://officeupdate.microsoft.com/office/webarchive.htm ------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" NEUMONIA HOSPITALARIA

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------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/master19.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" NEUMONIA HOSPITALARIA
NEUMONIA HOSPITALARIA
Prof. Dra. Adelina Braselli
AGOSTO - 2002
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DEFINICIÓN Y EPIDEMIOLOGÍA
nDEFINICI&Oacu= te;N:
nFIEBRE Y NUEVO INFILTRADO PULMONAR, DESPUÉS DE 72 HORAS DE LA HOSPITALIZACIÓN Y QUE NO LA ESTABA INCUB= ANDO ANTES
n<= span lang=3DES-TRAD style=3D'font-size:56%;display:none'>
nEPIDEMIOLOG&I= acute;A
nINFECCIÓN HOSPITALARIA FRECUENTE
n<= span lang=3DES-TRAD style=3D'font-size:56%;display:none'>
nPACIENTES CON INTUBACIÓN TRA= QUEAL O VM TIENEN UN RIESGO DE NEUMONÍA NOSOCOMIAL 6 A 20 VECES MAYOR <= /div>
n
n1er=  CAUSA DE MUERTE POR INFECCIÓ= ;N NOSOCOMIAL
n
nMAYOR MORBIMORTALIDAD EN PACIENTES INTERNADOS EN UCI, ESPECIALMENTE LOS SOMETIDOS A VENTILACIÓN MECÁNICA =
n<= span lang=3DES-TRAD style=3D'font-size:56%;display:none'>
nSOBRECARGA EN DÍAS DE HOSPITALIZACIÓN Y COSTOS ECONÓMICOS
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file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/slide0018.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" NEUMONIA HOSPITALARIA
PATOGENIA
nDEBE OCURRIR UNA DE ESTAS CONDICIONES: =
n
nCOM= PROMISO DE LAS DEFENSAS DEL HUÉSPED
n
nIN&= Oacute;CULO SUFICIENTEMENTE GRANDE, QUE SOBREPASE LAS DEFENSAS DEL HUÉSPED
n
nMIC= ROORGANISMO DE SUFICIENTE VIRULENCIA
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PATOGENIA
Ø= MICROASPIRACIÓN DE SECREC= IONES OROFARÍNGEAS:
n<= span lang=3DES-TRAD style=3D'font-size:50%;display:none'>
nLa colonización de la orofaringe con gérmenes nosocomiales es la principal fuente de origen de la infección.
nLa frecuencia de colonización aumenta con la severidad de la enfermedad de base.
nLa colonización es precoz, d= entro de los 4 primeros días.
nLa colonización gástr= ica precediendo a la coloización de la vía aérea fue demostrada en una minoría de pacientes
n
nEl 2º paso es la microaspiración con llegada del patógeno al= tracto respiratorio bajo.
nEl riesgo de microaspiración= aumenta con el decúbito dorsal, si hay alteración de <= span style=3D'position:absolute;top:72.5%;left:17.79%;width:87.82%;height:3.75%= '>conciencia, trastornos deglutorios,= sonda nasogástrica, tubo endotraqueal, reflujo gastroesofágico. =
n<= span lang=3DES-TRAD style=3D'font-size:50%;display:none'>
nOTROS MECANISMOS= MENOS FRECUENTES:
Ø= DISEMINACIÓN HEMATÓGE= NA DESDE FOCO DISTANTE
Ø= PENETRACIÓN EXÓGENA (= ej.: toracostomía)
n
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FACTORES DE RIESGO PARA NIH (1)
nRELACIONADOS CON EL PACIENTE= :
= n
ü= edad;
ü= malnutrición/obesidad; =
ü= hábito de fumar; abuso de al= cohol; UDIV;
ü= EPOC; 
ü= otra comorbilidad (aguda o cr&oacut= e;nica);
ü= inmunosupresión; =
ü= alteración de conciencia; &#= 13;
ü= disfunción diafragmát= ica y bloqueo neuromuscular;
ü= hospitalización prolongada.<= /span>
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FACTORES DE RIESGO PARA NIH (2)
§
nRELACIONADOS CON EL CONTROL DE <= /b>INFECCIONES:
ü
ü= lavado de manos;
ü= uso de guantes; =
ü= desinfección de equipos; = ;
ü= condiciones del ambiente;
ü= infección cruzada paciente/paciente.
n
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FACTORES DE RIESGO PARA NIH (3)
nRELACIONADOS CON LA INTERVENCI&O= acute;N:
ü
ü= prolongada o repetida administraci&= oacute;n de antibiótico;
ü= uso de  sedantes, analgésicos narcóticos e = inmunosupresores;
ü= alcalinización del medio gástrico;
ü= alimentación enteral;
ü= intubación endotraqueal; FBC= ; LBA; broncoaspiración;
ü= sinusitis maxilar (aumenta con intubación nasogástrica o nasotraqueal);
ü= cirugía: cabeza, cuello, tórax y abdomen.&= #13;
= n
n<= span style=3D'font-size:88%;mso-special-format:lastCR;display:none'>
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ETIOLOGÍA
nBACTERIAS: 80= A 90%, VIRUS 10 A 20%, HONGOS < 1%.
n=
nGÉRMEN= ES MÁS FRECUENTES:
nEnterobacilos (E. coli, especies de Klebsiella, Proteus, Enterobacter, Serratia)
n
nOtros bacilos gram negativos: espec= ies de Pseudomonas y Acinetobacter  = 3;
n<= span lang=3DES-TRAD style=3D'font-size:63%;display:none'>
nS. aureus
n=
nMEN= OS FRECUENTES : Streptococcus pneumoniae, Hemophilus influenzae y Moraxella catarrhalis en EPOC, anaerobios en neumonías aspirativas, hongo= s en inmunodeprimidos.
n= 3;
n= 3;
n<= span style=3D'font-size:88%;mso-special-format:lastCR;display:none'>
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ETIOLOGÍA
= nCOMIENZO TEMPRANO < 5 d&iacut= e;as:
nStreptococcus pneumoniae,
nHemophilus influenzae, <= /span>
nStaphylococcus aureus meticilinosensible,
nAnaerobios
n<= span lang=3DES-TRAD style=3D'font-size:75%;display:none'>
nCOMIENZO TARDÍO > 5 días:
nEnterobacterias: E. coli, especies de Klebsiella, Proteus, Enterobacter, Serratia,
nEspecies de Pseudomonas, Acinetobacter
nS.aureus meticilinoresistente
n<= span lang=3DES-TRAD style=3D'font-size:75%;display:none'>
n
n
n
n
n
n
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DIAGNÓSTICO
nFIE= BRE + SÍNTOMAS RESPIRATORIOS + NUEVO = INFILTRADO PULMONAR
n=
nOBJETIVOS DEL DIAGNÓSTICO:
n
n1) DETERMINAR SI ES UNA NEUMONIA U = OTRO PROCESO CO= MO: INFARTO DE PULMÓN, INSUFICIENCIA CARDÍACA CONGESTIVA, DISTRÉS RESPIRATORIO
n
n2) DETERMINAR LA ETIOLOGÍA&#= 13;
n
n3) DETERMINAR LA SEVERDAD DE LA NEUMONÍA PARA DEFINIR EL LUGAR DE TRATAMIENTO
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MANEJO CLÍNICO
n=
nBACTERIOLOGÍA DEL ESPUTO: po= ca sensibilidad y poca especificidad
nHEMOCULTIVOS: diagnóstico en= 8 a 20%
nHEMOGRAMA
nGASOMETRÍA EN SANGRE ARTERIA= L
nESTUDIO DE FUNCIÓN HEP&Aacut= e;TICA Y RENAL
nSEROLOGÍA: poco útil&= #13;
n<= span lang=3DES-TRAD style=3D'font-size:63%;display:none'>
nTÉCNICAS INVASIVAS: (casos seleccionados, falla terapéutica, inmunodeprimido, sospecha de carcinoma)
üFBC con cepillado brónquico = distal protegido o LBA;
üBTB, PATT, TC, BPCA.
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SELECCIÓN DEL PLAN ANTIBIÓTICO
nPARA SELECCIONAR EL PLAN ANTIBIÓTICO EMPÍRICO <= span style=3D'position:absolute;top:33.0%;left:19.1%;width:80.14%;height:4.75%'= >PRECOZ, LA ATS IDENTIFICA GRUPOS SEGÚN:
n
nSEVERIDAD DE NEUMONÍA (MEDIANA-MODERADA O ALTA
n
nFACTORES DE RIESGO PARA  DETERMINADOS PATÓGENOS = ;
n= 3;
nCOMIENZO: PRECOZ (< 5 DÍA= S) O TARDÍO (> 5 DÍAS)
n<= span lang=3DES-TRAD style=3D'font-size:63%;display:none'>
nMANTENER EL P= LAN 72 HORAS =
n= 3;
nPUEDE SER NEC= ESARIO CAMBIARLO EN BASE = A:
n
¬<= /span>resultados microbiológicos: = de hemocultivo y esputo,  <= /span>
¬<= /span>respuesta al tratamiento.
n= 3;
n
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DEFINICIÓN DE SEVERIDAD
nNECESIDAD POTENCIAL DE VENTILACI&Oa= cute;N MECÁNICA O MONITOREO
n
nFAL= LA RESPIRATORIA
n
nR&A= acute;PIDA PROGRESIÓN RADIOLÓGICA O NEUMONIA MULTILOBAR
n
nFAL= LA MULTIORGÁNICA
n
nSHO= CK, HIPOTENSIÓN, OLIGURIA (DIURESIS HORARIA < 20 CC), FALLO RENAL QUE REQUIERE DIÁLISIS
n
n
n
n
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FACTORES DE RIESGO PARA AGENTES ESPECÍFICOS:
qBacilos gram negativos entér= icos – colonización orofaringea, colonización gástrica
q
qPseudomonas aeruginosa – estadía en UCI, VM, antibioterapia previa, corticoterapia, enfermedad pulmonar estructural
q
qAcinetobacter – antibioticoterapia previa
q
qStaphylococcus aureus= – diabetes, UDIV, falla rena= l
q<= span lang=3DES-TRAD style=3D'font-size:63%;display:none'>
qPolimicrobiana - 50% de los sometid= os a ventilación mecánica, neumonía de mecanismo aspirativo
q<= span lang=3DES-TRAD style=3D'font-size:63%;display:none'>
qAnaerobios (colonizantes de orofari= nge) - broncoaspiración
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= 3DOrganigrama
IDENTIFICACIÓN DE GRUPOS PARA EL TRATAMIENTO EMPÍRICO (ATS= )
SEVERIDAD
MEDIANA  - = ;
MODERADA
ALTA <= /div>
SIN FACTORES
DE RIESGO
CON FACTORES
DE RIESGO
SIN FACTORES
DE RIESGO
CON FACTORES
DE RIESGO
COMIENZO
TEMPRANO O TARDÍO
GRUPO 1 <= /div>
COMIENZO
TEMPRANO O TARDÍO
GRUPO 2 <= /div>
COMIENZO
TEMPRANO
GRUPO 1 <= /div>
COMIENZO
TARDÍO
GRUPO 3 <= /div>
COMIENZO
TEMPRANO O TARDÍO
GRUPO 3 <= /div>
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TRATAMIENTO EMPÍRICO – GRUPO 1-
Betalactámicos:
Cefalosporina G II o G III
O aminopenicilina/IBL
Alérgico a betalactámicos:
ciproxina + clindamicina
Streptococcus pneumoniae Haemophilus influenzae <= /span>
Staphylococcus aureus meticilinosensible
Bacilos gram negativos entéricos (E. coli, especies de Proteus., Klebsiella., Serratia., Enterobacter)
PLAN ATB
GÉRMENES
------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/slide0007_image007.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhzgH1AHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAADM AfMAgAAAAAAAAAL/jI+py+0Po5y02ouz3rz7D4YfQJbmiabqyrbuC8fyTNf2nQb4zvf+DwzCDsKi 8YhMKnPLpvMJ3RGj1Kr1OtNht9yu1OANi8dALfmM3k7T7Dbb7I7Lg+u5/f6E4/d8Vr0PGHijJ1h4 92eYqHhCuOhIhvgoCdg4aXkVeakZV7npuZT5KSrWOWpaBnaqGla66loT+iqr1Dpr65d6q5tUu+sL EPsrDDtczJhrnEzTq+wa3Axtwhxt+kwNPX39aa2dnN2tyQ0+/D0+KW7uW57uiM5+u/6e6C4vG18v SI+/er/fp++vWkBRAAduM+ipIMJwC8MhawgPoiURFCtavIgxo8aN/xw7etQocVe/kG8eknR2sp3J lKdGshyj8GUhlzK9xKxJCWe+lToZ9vzH8+c5oXxuEp1D82gUo0rdJG3qhCnUNE+n0gpqNV9Wp1i3 /vNasirYLmLHoiprFlNaSF3XykHrFofUuFbg0oXV9i5VvVzm8s3zF4vfwKAI181r2GZiKoMXG7Hr WEXjyHQoR0VsuQrkzCUmc+ax+bPnz3JJIxltmljqIqhXywjNubXrIbPpYK59BHZm2bj99PbB+zcT 4V90E2d0XO7t5D2MUw7OHFh0vM6ZV3cM3fr0Zcu327i+OHty8InFHydv2Dxx9ITVC2cf2P1v+H/l 96bP1z5u/Hr11//mf5d/swFIl4CuERiXgash6JaCqTG4loOmQZiWhKRRaJaFonn3WnccZvHhEB6G SBuJLWgYm4knjqiiby1KxuKLw8l4DIa70YgCijfiKE2MPJJgI1g6WhakV0M+92NnPv5Y5FZHRtZk Vk9ilySQS/IYpVVThlclMFfimOVUW5bX5ZjplfkljWFCZWZ7aK7pZpVtxvdml9/VaecyeOb52p58 lpjknPX5+acLcColaH6EFupioGnKeOhRifa3KKOSVWppjphmKs2mnALp6aeREjVpgKFyOqpQpRZ4 aqap/rRqgq1a+mpPsTY4K6O16nRrhLkWuitOvVb465/B1jRshsX/8nmsTMmO1exLzwq5bJ7RsjSt kdXaeW1K2Tq5bZnhyjluoOUyeS6W6YK5rprtQvrui92e9K2U8bY4L0n1anmvivmGtK+Y/Zr4r0QB szkwiQVDdHBTCzfUMKIJh/jwQhFLOvGHFSN0MakZc7ixQR2r+rF3IQ80Mqwlb3dyQCnbuvJ0Lfvz Mq8xRzfzPjULe7N2cj4qb8/jCX0e0esZ/R7S8yl9H9P7Of0f1ANKfSDVC1r9INYTan0h1xv+nLPN YH/aKJNA4+t1imOTfenabGvq9tudxi03qHTXHXY9OyOb9o6O5s333XID/s7ezvZNJOJICv424ewY Lq3iUEpOJeNsbzueDuTYUs6l5WRjbo7m3nJOpueikn6m6aiiHuffdSOnuqus0xk7rbMPWruutyua O7C7U9q7sb+bGjyzw7NavLXHy5o8t8vj2ry40ZM7vbnVo3u9umB/xH333n8Pfvjij09++eafj376 6q/PfgMFAAA7 ------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/slide0008.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" NEUMONIA HOSPITALARIA
TRATAMIENTO EMPÍRICO – GRUPO 2 -
* Riesgo de aspiración: Aminopenicilina/IBL
O ceftriaxona (o cefotaxime) + clindamicina
* Riesgo de Pseudomonas: aminósido (o FQ) +=   betalactámico antipseudomonas:
ceftazidime o cefoperazona o = imipenem o piperazilina/tazobact= am)
* Riesgo de Staphylococcus: vancomicina hasta que demuestre ser meticilinosensible<= span style=3D'font-size:64%;mso-special-format:lastCR;display:none'>
LOS MISMOS AGENTES QUE EN GRUPO 1
ADEMÁS: anaerobios, Staphylococcus aureus, Pseudomonas aeruginosa
PLAN ATB
GÉRMENES
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TRATAMIENTO EMPÍRICO – GRUPO 3 -
Betalactámico antipseudomonas: Ceftazidime o imipenem o piperacilina/tazobactam)
+ aminósido (o ciprofloxacina)
* Sospecha MRSA: + vancomicina
LOS MISMOS AGENTES QUE EN GRUPO 1
ADEMÁS: P. aeruginosa, Acinetobacter spp., SAMR
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application/javascript; charset="us-ascii" function LoadSld() { var sld=3DGetObj("SlideObj") if( !g_supportsPPTHTML ) { sld.style.visibility=3D"visible" return } if( MakeNotesVis() ) return runAnimations =3D _InitAnimations(); if( IsWin("PPTSld") ) parent.SldUpdated(GetSldId()) g_origSz=3DparseInt(SlideObj.style.fontSize) g_origH=3Dsld.style.posHeight g_origW=3Dsld.style.posWidth g_scaleHyperlinks=3D(document.all.tags("AREA").length>0) if( g_scaleHyperlinks ) InitHLinkArray() if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) ) document.body.scroll=3D"no" _RSW() if( IsWin("PPTSld") && parent.IsFullScrMode() ) FullScrInit(); =09 MakeSldVis(); ChkAutoAdv() if( runAnimations ) { if( document.all("NSPlay") ) document.all("NSPlay").autoStart =3D false; if( sld.filters && sld.filters.revealtrans ) setTimeout( "document.body.start()", sld.filters.revealtrans.duration * = 1000 ); else document.body.start(); } } function MakeSldVis() { var fTrans=3Dg_showAnimation && SldHasTrans() 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{ return sId=3Dlocation.href.substring(location.href.la= stIndexOf('/')+1) } function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx= tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl= e.display=3D'none'; return true } return false } function IsWin( name ) { return window.name =3D=3D name } function IsNts() { return IsWin("PPTNts") } function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) } function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"= && navigator.appVersion.indexOf("Windows")>0 ) } function SupportsPPTHTML() { var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0 if( msie >=3D 0 ) ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) ) else ver=3DparseInt(appVer) return( ver >=3D 4 && msie >=3D 0 ) } function _RSW() { if( !g_supportsPPTHTML || IsNts() || ( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) ) return var padding=3D0; if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6 cltWidth=3Ddocument.body.clientWidth-padding cltHeight=3Ddocument.body.clientHeight-padding factor=3D(1.0*cltWidth)/g_origW if( cltHeight < g_origH*factor ) factor=3D(1.0*cltHeight)/g_origH newSize =3D g_origSz * factor if( newSize < 1 ) newSize=3D1 s=3DSlideObj.style s.fontSize=3DnewSize+"px" s.posWidth=3Dg_origW*factor s.posHeight=3Dg_origH*factor s.posLeft=3D(cltWidth-s.posWidth+padding)/2 s.posTop=3D(cltHeight-s.posHeight+padding)/2 if( g_scaleHyperlinks ) ScaleHyperlinks( factor ) } function _InitAnimations() { animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined'; isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode(); g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc= reen && parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } } function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) || (event && (event.keyCode=3D=3D32) ) ) parent.GoToNextSld(); } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"Fin de la presentación, haga clic para salir.", = SCREEN_MODE=3D"Frames", gIsEndShow=3D0, NUM_VIS_SLDS=3D18, SCRIPT_HREF=3D"s= cript.js", FULLSCR_HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0001.htm",1,-1,1),new hrefList(= "slide0002.htm",1,-1,1),new hrefList("slide0018.htm",1,-1,1),new hrefList("= slide0003.htm",1,-1,1),new hrefList("slide0004.htm",1,-1,1),new hrefList("s= lide0013.htm",1,-1,1),new hrefList("slide0014.htm",1,-1,1),new hrefList("sl= ide0005.htm",1,-1,1),new hrefList("slide0017.htm",1,-1,1),new hrefList("sli= de0015.htm",1,-1,1),new hrefList("slide0016.htm",1,-1,1),new hrefList("slid= e0010.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList("slide= 0012.htm",1,-1,1),new hrefList("slide0006.htm",1,-1,1),new hrefList("slide0= 007.htm",1,-1,1),new hrefList("slide0008.htm",1,-1,1),new hrefList("slide00= 09.htm",1,-1,1)); function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) { var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix(); function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') { href=3Dnew String(document.location.href) Start=3Dhref.indexOf('!')+1 End=3Dhref.lastIndexOf('/')+1 if (End < Start) return href.substring(0, Start) else return href.substring(0, End) } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ToggleOtlPane() { frmset=3Ddocument.all("PPTHorizAdjust") frm=3Ddocument.all("PPTOtl") if( gOtlOpen ) frmset.cols=3D"*,100%" else frmset.cols=3D"25%,*" gOtlOpen=3D!gOtlOpen frm.noResize=3D!frm.noResize UpdOtNavPane() } function ToggleNtsPane() { frmset=3Ddocument.all("PPTVertAdjust") frm=3Ddocument.all("PPTNts") if( gNtsOpen ) frmset.rows=3D"100%,*" else frmset.rows=3D"*,20%" gNtsOpen=3D!gNtsOpen UpdNtsPane() } function ClearMedia() { if (PPTSld.pptSound) 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FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else return gCurSld } function GetNumSlds() { if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document doc.open() doc.writeln('


' + ENDSHOW_MESG + '

') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); function ImgBtn( oId,bId,w,action ) { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } function TxtBtn( oId,oeId,action,chkState ) { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new TxtBtn( "nb_nts","nb_ntsElem",parent.ToggleNtsPan= e,GetNtsState ) gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","nb_prevBorder",30,parent.GoToP= revSld ) gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","nb_nextBorder",30,parent.GoToN= extSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D new ImgBtn( "nb_voice","nb_voiceBorder",18,parent.= ToggleVNarration ) gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlTxt","nb_otlTxtBorder",23,parent= .ToggleOtlText ) gBtnArr["nb_nts"].m_flagId=3D "notes_flag" gBtnArr["nb_nts"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState var sNext=3D"Siguiente",sPrev=3D"Anterior",sEnd=3D"Fin de la presentaci&oac= ute;n",sFont=3D"Arial",sArrow=3D"Flecha",sFreeform=3D"Forma libre",sRect=3D= "Rectángulo",sOval=3D"Óvalo" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { history.back(); PPTSld.event.ca= ncelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; s.fontFamily=3DsFont s.fontSize=3D"9pt" s.paddingLeft=3D2 } function CreateSeparator( node ) { var sObj=3DCreateItem( node ) SetCMBorder(sObj,"menu","menu") var s=3DsObj.style s.borderTopColor=3D"threedshadow" s.borderBottomColor=3D"threedhighlight" s.height=3D1 s.fontSize=3D"0px" } function CreateItem( node ) { var elem=3DPPTSld.document.createElement("DIV") node.insertBefore( elem ) return elem } function SetCMBorder( o,ltClr,rbClr ) { var s=3Do.style s.backgroundColor=3D"menu" s.borderStyle=3D"solid" s.borderWidth=3D1 s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr } ------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/fullscreen.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; 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charset="us-ascii" NEUMONIA HOSPITALARIA ------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii"
Presentac= ión
Esquema
------=_NextPart_01C28063.34D09E00 Content-Location: file:///C:/86E1D161/NEUMONIAHOSPITALARIA_archivos/filelist.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C28063.34D09E00--