Manejo no

farmacológico del
dolor

T.O. Evelyn Alvarez E.

 Temario
1. Definición Intervenciones no Farmacológicas
2. Algunos Mitos del dolor en ICU
3. Principales intervenciones
1. Realidad virtual / hipnosis
2. Masaje
3. Música
4. Frio
5. Relajación
4. Consideraciones
 Intervenciones no Farmacológicas (InF)

• Son intervenciones no invasivas basadas en la ciencia.

• Su objetivo es prevenir, cuidar o curar problemas de salud.

• Pueden consistir en productos, métodos, programas o

servicios, cuyos contenidos son manejados por los usuarios.

• Están vinculados a procesos conductuales, motores y / o

psicológicos identificados en estudios clínicos.

(Plateforme CEPS, 2017).

• Tienen un impacto medible en marcadores en salud, la
calidad de vida, el comportamiento y marcadores
socioeconómicos.

• Su implementación requiere habilidades relacionales,

comunicativas y éticas.
(Plateforme CEPS, 2017).

• Son complementarias a los tratamientos biológicos o

quirúrgicos, potenciando su acción.
(Ninot, 2019).
•

ALGUNOS MITOS
ACERCA DEL DOLOR
EN UCI
MITO 1: LA MAYORÍA DE LOS PACIENTES CRÍTICOS
RECIBEN ADECUADO MANEJO DEL DOLOR

• Priorizar manejo del dolor

• Educar al equipo sobre evaluaciones y

tratamientos del dolor

• Implementar mejoras en la calidad y

responsabilidades para el control del dolor

• Evaluar constantes y que los pacientes puedan

reportar el dolor

Crit Care Med 2015; 43: 2468-2478

MITO 2: DOLOR NO AFECTA A CORTO Y LARGO
PLAZO

Uso de protocolos
Crit Care Med 2015; 43: 2468-2478
 MITO 3: EL CONTROL DEL DOLOR EN UCI ES
RESPONSABILIDAD DE ENFERMERÍA
• Formar un equipo multidisciplinario para el
manejo del dolor.

• Evaluar la calidad y seguridad de las prácticas

actuales de manejo del dolor.

• Utilizar enfoques basados en la evidencia que

incluyen pautas, protocolos, listas de
verificación y objetivos diarios para el dolor.

• Establecer métodos continuos para la mejora

de procesos.

• Integrar al equipo de dolor, para mejorar los

Crit Care Med 2015; 43: 2468-2478 resultados del dolor y reducir la carga del
equipo de UCI
 INTERVENCIONES NO
FARMACOLÓGICAS EN DOLOR
1.- Realidad virtual

Virtual Reality for Pain Management in Cardiac Surgery .

CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL
NETWORKING Volume 17, Number 6, 2014
 • 67 pacientes
• Sesiones de 30 minutos
• Se evalúo pre – post :
• Grabaron signos vitales
• Se aplico encuesta con escala de Likert
• Se evalúo pre – post :
• 88% reportaron disminución nivel de dolor
• 3,75 en escala de likert (severo a ligero)
• 37.3% ↓FC; 52,2% ↓PA

Virtual Reality for Pain Management in Cardiac Surgery .

CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING Volume 17,
Number 6, 2014
 2.- Hipnosis

PROTOCOLO HIPNOSIS UTILIZADO

Criterios inclusión: 18 años, al • Preparar el escenario
menos 24 horas en ICU, • Enlentecer la respiración y la relajación
consentimiento de hipnosis.
• Sugestión para profundizar la relajación
Se considero extensión de la
• Sugestión para el control del dolor
quemadura, lesión inhalación´, el
índice abreviado de lesión por • Despertar.
quemadura, SAPS II, parámetros
fisiológicos.
 3.- Masajes

Son definidos como cualquier

forma sistemática de contacto o
manipulación realizada en los
tejidos blandos del cuerpo que
proporciona comodidad y
promueve la salud
 Characterization of massage interventions between evaluated studies

Study N Diagnosis Other Massage Massage frequency Body area

intervention duration

Boitor et al., 40 Cirugia Posicionamie 15 minutes 2 to 3 massage sessions Hands

2015 Control 19 cardiaca nto over 24 hours
Inter. 21 confortable
Kshettry, 104 Cirugia Mùsica 30 minutes Once or twice Not specified
2006 Control 51 cardiaca instrumental
Interv 53 o clasica
Técnicas de
imagineria
Mitchinson 605 Abdominal 20 minutes Once daily up to day 5 Back
et al., 2007 Standard 203 o toracica
(4) Atención ind.
202
Massage 200
Piotrowski 202 Abdominal Preparación 10 minutes Twice daily up to day 7 Back
et al, 2003 Tradicional 55 o toracica del ambiente
(5) Atención
focalizada 66
Masaje 81
 4.- Musica
• Escuchar música disminuye la intensidad del dolor o
requerimientos de analgesia , además permite la distracción
durante intervenciones.

• Estrategia de bajo costo, fácil implementación y segura.

• NO CONFUNDIR EL USO DE UN PROTOCOLO MUSICA CON

MUSICOTERAPIA
 Music interventions for mechanically ventilated patients
(Review)

Bradt J, Dileo C

Analysis 1.1. Comparison 1 Music versus standard care, O utcome 1 State Anxiety (change scores).

Review: Music interventions for mechanically ventilated patients

Comparison: 1 Music versus standard care

Outcome: 1 State Anxiety (change scores)

Std. Std.
Mean Mean
Study or subgroup Music Control Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95%CI IV,Random,95% CI

Chlan 1997 24 -7.17 (3.85) 27 -1.55 (4.08) 20.3 % -1.39 [ -2.01, -0.77 ]

Han 2010 44 -10.7 (6.82) 49 -0.76 (4.97) 22.0 % -1.67 [ -2.14, -1.19 ]

Lee 2005 32 -1.6 (3.81) 32 -1 (3.31) 21.8 % -0.17 [ -0.66, 0.32 ]

Wong 2001 10 -14 (5.62) 10 -3.84 (4.97) 14.5 % -1.83 [ -2.92, -0.75 ]

Wu 2008 30 -4.43 (7.19) 30 0.83 (6.88) 21.4 % -0.74 [ -1.26, -0.21 ]

Total (95% CI) 140 148 100.0 % -1.11 [ -1.75, -0.47 ]

Heterogeneity: Tau2 = 0.42; Chi2 = 23.42, df = 4 (P = 0.00010); I2 =83%
Test for overall effect: Z = 3.42 (P = 0.00063)
Test for subgroup differences: Not applicable

-4 -2 0 2 4
Favours music Favours control

Cochrane Database of Systematic Reviews 2014,

Study Music type Music duration Pain management

Broscious 1999 (1) Participant’s choice 10 minutes Procedural (chest tube removal)

Chan 2007(2) Participant’s choice (soft, slow music 45 minutes Procedural (C-clamp)
without lyrics)

Cooke et al., 2010 Participant’s choice (classical, jazz, 15 minutes Procedural (turning)
(3) country western, new age, or other)

Chiasson et al., Harp live music 10 minutes Non-procedural

2013 (4)

Jaber 2007 (5) Participant’s choice (U method) 20 minutes Non-procedural

Kshettry 2006 (6) Participant’s choice (light instrumental, 20 minutes Non-procedural

country western, or classical)

Ozer 2013 (7) Participant’s choice (Turkish classical, 30 minutes Non-procedural

folk or art music)
 Consideraciones

1. Se puede recoger aspectos históricos con familiares o

paciente a cerca de gustos y preferencias

2. Considerar diversos temáticas musicales ségun horarios del

día, de forma de apoyar al manejo ambiental

3. Evitar tener muchos estímulos de forma simultanea, ej: TV ,

radio, al mismo tiempo de atención del equipo o familia
 5.- Terapia de Frío
• La aplicación de frío ha sido usada
por años para aliviar el dolor.

• El frío, podría hacer una anestesia

local, además disminuir el edema,
metabolistmo celular, y flujo
sanguineo local.

• Realiza vasoconstricción local

relacionada al frío, limitando el
proceso inflamtorio y disminuyendo
el dolor muscular.
 Comparison of I ce PacksApplication and Relaxation
Therapy in Pain Reduction during Chest Tube
Removal Following Cardiac Surgery
H eidari Gorji M A, Bagheri N esami M , Ayyasi M , Ghafari R1, Yazdani J2

Departments of Nursing and M idwifery, 1Heart Surgery, and 2Biostatistics, M azandaran University of M edical Science,
Sari, Iran

Abstract
Background: Usually the chest tube removal (CTR) has been described as one of the worst experiences by patients in the intensive care
unit. Aim: This study aimed to compare the effects of cold therapy and relaxation on pain of CTR among the patients undergoes coronary
artery bypass graft surgery. Materials and Methods: This single-blinded clinical trial was done on 80 post-cardiac surgery patients in the
heart hospital of Sari-Iran. The patients were assigned to three randomized groups that included cold therapy, relaxation, and control groups.
Data analysis was done by T-test, Chi-square, generalized estimating equations and repeated measures analysis variance tests. Results: The
groups had no signifi cant differences in pain intensity before CTR (P = 0.84), but immediately after CTR there was a signifi cant difference
between the treatment (cold application and relaxation groups) and control groups (P = 0.001). There was no signifi cant difference between
relaxation and cold therapy groups. Conclusion: Regarding the relaxation and cold application methods showed relatively equal effects
on reducing the pain owing to CTR. Thus, the use of relaxation because of economics, without side effects, easy to use and effective is
recommended by the authors to the practitioners.

Keywords: Chest tube removal, cold application, coronary artery bypass grafting, pain, relaxation
Address for correspondence: Dr. Mitra Ayyasi, Department of Nursing and Midwifery, Mazandaran University of Medical Science, Vali asr
avenue-47636-5481, Sari, Iran. E-mail: Gorjim29@yahoo.com

Introduction the patient, mechanical irritation of the heart and

According to American Heart Association, annually more
than 448,000 patients underwent cardiothoracic surgery
including coronary artery bypass grafting (CABG), valve
replacement or repair, or repair of structural defects.[1]
Inserting chest tubes (CT) after CABG was aimed to
maintain heart and lung functioning and essential
to prevent from pleural effusion, pneumothorax and
pericardium, and an increased incidence of infection.[4]
The chest tubes are typically removed within 24-48 hours
after surgery or when the excess air, blood, or fluid has
been properly drained.[5,6] Chest tubes removal (CTR)
after surgery has been described as one of the worst
experiences among these patients.[2,5,7,8] Studies showed
that moderate to severe pain has been reported by
6.- Relajación

Mindfulness o reducción del estrés basado en atención plena

Técnicas de respiración

Meditación

Entrenamiento autógeno

Visualización o Imaginación guiada

Relajación progresiva de Jacobson

 ISSUES IN PAIN MANAGEMENT

Comparison of two pain-management strategies

during chest tube removal: Relaxation exercise
with opioids and opioids alone
Stacy A. Friesner, RN, M S, ACNP, Donna M iles Curry, PhD, RNC, and Gail R. M oddeman, PhD, RN

PURPOSE: The purpose of this study was to determine whether the use of a slow deep-breathing
The breathing exercises included inhaling slowly through the nose and
relaxation exercise, when used as an adjunct to opioid analgesia, decreases pain during chest tube
removal (CTR) after coronary bypass surgery.
exhaling slowly through
DESI GN:pursed lips. Thesepretest/
A two-group quasi-experimental subjects initiated
posttest design was used. the technique 5
minutes before removal. The subjects either closed their eyes or fo-cused on
SAM PLE: A convenience sample of 40 adults who had undergone coronary artery bypass graft surgery
and met all inclusion criteria were recruited before CTR.
an object within theSETTI
room. NG: DataWhile theinsubjects
were collected continued
the Cardiothoracic Surgical Intensive with the
Care Units relaxation
of three acute care
facilities in the M idwestern United States.
technique, both theMchest
ETHOD: Atube dressing
10-cm vertical and
Visual Analog sutures
Scale was were
used to measure pain atremoved.
three points: before CTR,
immediately after CTR, and 15 minutes after CTR. The experimental group received slow breathing
relaxation exercises in addition to the usual opioid doses administered.
FI NDI NGS: Data were analyzed using analysis of variance, and multivariate analysis of covariance
yielded a significant difference in pain ratings immediately after CTR and 15 minutes after CTR for the
 CONSIDERACIONES FINALES
• Las InF utilizadas para el manejo del dolor, no tienen
suficiente evidencia en cuanto a:
• Eficacia
• Uso (procedimientos/sin procedimientos)
• Protocolos
• Técnicas

• Se requiere crear protocolos acordes a las necesidades

de los centros y pacientes, de forma de validar estas
propuestas