www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
The
effects
of
music
therapy
in
patients
undergoing
septorhinoplasty
surgery
under
general
anesthesia
夽
Erhan
Gökc
¸ek
∗,
Ayhan
Kaydu
DiyarbakırSelahaddinEyyübiStateHospital,DepartmentofAnesthesiologyandReanimation,Diyarbakır,Turkey Received28August2018;accepted10January2019
Availableonline5March2019 KEYWORDS Musictherapy; Generalanesthesia; Pain; Postoperative recovery Abstract
Introduction:Musichasbeenusedforseveralyearsasarelaxationmethodtoreducestressand anxiety.Itisapainless,safe,inexpensiveandpracticalnonpharmacologictherapeuticmodality, widelyusedallovertheworld.
Objectives: Weaimedtoevaluatetheeffectofmusictherapyonintraoperativeawareness, patientsatisfaction,awakeningpainandwakingqualityinpatientsundergoingelective septo-rhinoplastyundergeneralanesthesia.
Methods:This randomized, controlled, prospective study was conducted with 120 patients undergoingseptorhinoplastywithina2monthsperiod.Thepatientswererandomlyselectedand dividedintotwogroups:groupmusic(musicduringsurgery)andcontrolgroup(withoutmusic duringsurgery).Allpatientsunderwentstandardgeneralanesthesia.Patientsaged18---70years whowouldundergoaplannedsurgeryundergeneralanesthesiawereincluded.Patientswho hademergencysurgery,hearingorcognitiveimpairment,wereexcludedfromthestudy.
Results:Atotalof120patientswereenrolled,andseparatedintotwogroups.Therewereno statisticallysignificantdifferencesbetweenthegroupsintermsofdemographiccharacteristics, anesthesiaandsurgerydurations(p>0.05).Inthemusicgroup,sedationagitationscoreswere lowerthanthoseinthecontrolgroupatthepostoperativeperiod(3.76±1.64vs.5.11±2.13;
p<0.001).Inaddition;inpatientsofthemusicgroup,thepainlevel(2.73±1.28vs.3.61±1.40) waslower(p<0.001),requiringlessanalgesicdrugsintake.
Conclusion: Musictherapy,whichisanonpharmacologicintervention,isaneffectivemethod, withoutsideeffects, leadingtopositiveeffectsintheawakening,hemodynamicparameters andanalgesic requirements inthepostoperative period.Itisalso effective inreducingthe anxietyandintraoperativeawarenessepisodesofsurgicalpatients.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:Gökc¸ekE,KayduA.Theeffectsofmusictherapyinpatientsundergoingseptorhinoplastysurgeryundergeneral anesthesia.BrazJOtorhinolaryngol.2020;86:419---26.
∗Correspondingauthor.
E-mail:gokcekerhan44@hotmail.com(E.Gökc¸ek).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2019.01.008
1808-8694/©2019Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE Terapiamusical; Anestesiageral; Dor; Recuperac¸ão pós-operatória
Efeitosdamusicoterapiaempacientessubmetidosarinosseptoplastiasobanestesia geral
Resumo
Introduc¸ão:A música temsidousada háváriosanoscomo ummétodo derelaxamentopara reduzir o estresse e aansiedade. Éum método de tratamentonão farmacológico, seguro, baratoeprático,amplamenteusadoemtodoomundo.
Objetivo:Avaliar o efeito da musicoterapia no despertar intraoperatório, nasatisfac¸ão do paciente,nadoraodespertarenaqualidadedevigíliaempacientessubmetidosà rinossepto-plastiaeletivasobanestesiageral.
Método: Estudoprospectivo,randomizado econtroladofeitocom120pacientessubmetidos arinosseptoplastia em2meses. Ospacientesforamselecionadosaleatoriamenteedivididos emdoisgrupos:musicoterapia(músicaduranteacirurgia)econtrole(semmúsicadurantea cirurgia).Todosospacientesforamsubmetidosaanestesiageralpadrão.Pacientesentre18e70 anosqueseriamsubmetidosacirurgiaplanejadasobanestesiageralforamincluídos.Pacientes submetidos acirurgia deemergência,apresentavamdeficiênciaauditivaoucognitivaforam excluídosdoestudo.
Resultados: Foraminclu¡dosnoestudo 120pacientes, divididosnos doisgrupos.Nãohouve diferenc¸asestatisticamentesignificantesentreosgruposemrelac¸ãoàscaracterísticas demo-gráficas,anestesia edurac¸ãodacirurgia (p>0,05).Nogrupo musicoterapia,osescores de agitac¸ãodasedac¸ãoforammenoresdoquenogrupocontrolenoperíodopós-operatório(3,76 ±1,64vs.5,11±2,13;p<0,001).Alémdisso,nospacientesdogrupomusicoterapia,onível dedor(2,73±1,28vs.3,61±1,40)foimenor(p<0,001)eanecessidadedeanalgésicosfoi menornopós-operatório.
Conclusão:A musicoterapia,uma intervenc¸ãonão farmacológica,é ummétodo eficaz,sem efeitoscolaterais,quelevaaefeitospositivosnodespertar,nosparâmetroshemodinâmicose nasnecessidadesanalgésicasnopós-operatório,alémdereduziraansiedadeporestresse,a doreachancededespertarduranteacirurgia.
© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
The rapid development of anesthesia techniques in the recent years, has gradually expanded the working areas of anesthesiologists outside the operating room, and the increase of the number of daily operations, have lead to an increase of the patients expectations regarding safety andcomfort.Anesthesiologistsareresponsibleforensuring thesafety and comfortof the patientbefore, duringand aftertheoperation,especiallyinside theoperationroom. Theincreasingresponsibilities,theexpectationsofpatients andtheirrelativesforceustoupdateourknowledgein anes-thesiapracticeandtodevelopnewmethods.1,2
Almostall of thepatients tobeoperated present with anxiety,begins at least two daysbefore the surgery. The anxietygraduallyincreasesintheoperationroom accompa-niedbyfeelingsoffear,doubtanddesperation.3 Increases
in respiratory rate, heart rate, blood pressure, plasma adrenalineand noradrenalin levelsaresome physiological responsestopre-surgical stressandanxiety.Inadditionto operations;theremovalofanxietyobservedinalmostallthe patientsduringthediagnosticorinvasiveprocedureswitha properpremedicationhasbecomearoutinepractice.4,5The
aimofthesedationistobringthepatientwhois confron-tedwithanxietyandpainfulattempts toapositionwhere theycansafelyandcalmlyundergotheanesthesiaand sur-gicalprocedures.However,thisisdifficulttoobtainbecause
ofthevariabilityofthesedationlevel,expectationsofthe patients, difference in the intraoperative conditions, and the differentpharmacokinetic and pharmacodynamic pro-pertiesoftheusedagents.6
Currently,pharmacologictreatmentoptionsforthe per-ioperative period anxiety and pain, and complementary medical interventions such as hypnosis, acupuncture and music therapy, are becoming increasingly more popular, eveniftheresultsarenotyetcompletelyknownyet.Music hasbeen usedfor severalyearsasarelaxationmethodto reducestressandanxiety.Itisapainless,safe,inexpensive andpracticablenonpharmacologictreatment, widelyused allovertheworld.7---9
Many studies have employed music therapy and other therapeuticsuggestionmethods,andithasbeen observed thatthepatients’surgicalanxietyhasdecreasedanda seda-tiveeffecthasbeen observedintheperioperativeperiod. Inadditiontotheanxiolyticandsedativeeffects,this the-rapyhasshortenedthedurationofpostoperativerecovery andhasreducedtheneedfor analgesicdrugs.Also,ithas beenreportedthatlisteningtomusicreducestheneedfor sedativedrugsandimprovessatisfactioninpatients under-going regional anesthesia.10,11 In a few studies conducted
in patients under general anesthesia, it has been conclu-dedthat musicandintraoperativetherapeutic suggestions havepositiveeffectsonpostoperativerecoveryand analge-sicconsumption.11---13
Enrollment
Allocation
Follow-Up
Analysis
Assessed for eligibility (n=200)
Excluded (n=80)
Not meeting includion criteria (n=65) Declined to participate (n=10) Other reasons (n=5)
Randomized (n=120)
Group C (without music) (n=60) Group M (with music during surgery) (n=60)
Lost to follow-up (give reasons) (n=0) Lost to follow-up (give reasons) (n=0) Discontinued intervention (give reasons) (n=0)
Analysed (n=60)
Excluded from analysis (give reasons) (n=0) Excluded from analysis (give reasons) (n=0) Analysed (n=60)
Discontinued intervention (give reasons) (n=0)
Received allocated intervention (n=60) Received allocated intervention (n=60)
Did not receive allocated intervention (give reasons) (n=0)
Did not receive allocated intervention (give reasons) (n=0)
Figure1 Flowchart.
Weaimedtodeterminethesedativeeffectsofmusicby preventingthe anxiety caused by thenoise in the opera-tingroominpatientswhounderwentseptorhinoplastyunder generalanesthesiaandtoinvestigate theeffectsofmusic onperioperativerespiratoryandhemodynamicparameters, analgesic consumption and occurrence of intraoperative awareness.
Material
and
methods
Patients
Thisrandomized,double-blind,andprospectivelyresearch wasconductedinasingleurbanstatehospital.The appro-valfortheresearchwasgrantedbytheInstitutionalEthics Committee(decisionno.2017/72,GaziYasargilTrainingand ResearchHospital Ethics Committee).Written and spoken informedconsentwasobtainedfromallpatients.Atotalof 120patientsbetweentheagesof18and70yearsundergoing septorhinoplastyundergeneralanesthesiawereincludedin thisstudy.Theirdemographiccharacteristics, ASA classifi-cation, age, height(cm)and weights(kg) were recorded. Patientswithhearingproblems,thoseunabletocooperate (duetodementia,mentalretardation,etc.),thosewithdrug or alcohol abuse history, and those who did not want to participateinthestudywereexcluded(Fig.1).
Preoperativeprocedure
Thepatientswererandomizedintotwogroups:musicgroup (groupM,n=60)andcontrol group(groupC,n=60).Only patients in the music group put on headphones (Philips, SHP1900)enclosingtheears,preventingpatientsfrom hea-ringthevoices andnoisesinside theoperation room.The intensityofthemusicsoundwassetatalevel(65decibels withastandardsoundlevelmeter)inwhichpatientswould feelcomfortablewhenasked.Duringthewholeoperation, allthepatientsinthemusicgrouplistenedtorelaxing indi-genous and foreign music (pop, arebesk, jazz, alaturka, classical,ethnic,MMP-3078)byamp3(Mpeg-1AudioLayer 3)deviceaccordingtotheirpreferences,untilthe anesthe-ticgases areinitiated. Classical music waschosen by the anesthesiologistforthepatientswhodidnotshowany spe-cificpreference(Fig.2).
Anesthesiamanagement
Thirtyminutesbeforesurgery,allpatientswere premedica-tedwith0.03mg/kgintramuscularmidazolam(Dormicum®, Roche).Duringtheanesthesiainduction,2.5mg/kgIV propo-fol(Pofol®),1g/kgfentanyl(Fentanyl®,Janssen)bolusIV, and1mg/kgIVarithmetic(Aritmal®,Adeka)wereapplied. Musclerelaxationwasachievedwith0.6mg/kgrocuronium (Esmeron®, 10m/mL, Organon). After endotracheal
intu-Figure 2 The application of music therapy under general anesthesia.
bation, 2% sevoflurane (Sevorane®, Abbot) was injected with40%oxygen ratein anesthesiamaintenance.In addi-tion to inhalation anesthesia, IV infusion of remifentanil (Ultiva,GlaxoWelcome)wasappliedat0.05---10g/kg/min. Theremifentanildosewasincreasedordecreasedwhenan increaseordecreaseofmorethan20%ofthebaseline sys-tolicarterialpressurewasobserved.An additionalmuscle relaxant was administered depending on the duration of theoperationandfollow-upoftheneuromuscularblockade. When theheart rate droppedbelow 50beats/min, 0.5mg atropinewasinjected;whenmeanarterialpressure(MAP) droppedbelow60mg,10mgofephedrinewasinjected.
Patient’sroutineelectrocardiography(ECG),noninvasive blood pressure and peripheral oxygen saturation (SpO2) werecontinuouslymonitored.Measurementsofheartrate, systolicarterial pressure(SAP), diastolic arterialpressure (DAP), and mean arterial pressure (MAP),peripheral oxy-gen saturation,and baselinevalues wererecorded. Heart rate,SAP,DAP,MAP,SpO2,andminimumalveolar concentra-tion(MAC) valueswererecordedoninduction,intubation, every 5min of anesthesia, every 15min and immediately after extubation. All measurements were accomplished withDatex-Ohmeda anesthesia equipment(AS/3, Datex®, Helsinki, Finland). The period from the beginning of the anesthesiainductionuntilthemomentthepatientwastaken totherecoveringroom,wasdefinedasthedurationofthe anesthesia;and theperiodof timefromthesurgical inci-siontotheskin closurewasdefinedasthedurationofthe surgery.
Postoperativeprocedure
Afterextubation,patientsweretakentothepostanesthetic careunit(PACU)for30min,tobeevaluated.ECG, noninva-sivebloodpressureandSpO2monitorswereanalyzed.
Datacollection
Sedationscoreswererecordedat0,5,15,30minaccording to six-grade Riker sedation-agitation scale (RSAS)14 with
peripheraloxygensaturation,SAP,DAP,OABmeasurements. Postoperativepainseveritywasassessedbyavisualanalog scale (VAS; 0---10cm) before departing the RSAS room. According to VAS (visual analog scale), if the patient’s painwere5 or more, an additional0.5mg/kg of petidine HCL(Aldolan®) IVwasadministered.Postoperative nausea andvomiting were recorded as‘‘yes’’ or ‘‘no’’. One day afterthe surgery, we also evaluatedthe patientwake-up
satisfaction using the EVAN-G scale15 and the data about
intraoperativeawareness.
Theprimaryaimofourstudywastoevaluatethepatient satisfactionafter surgery, while oursecond objectivewas toanalyzeintraoperativehemodynamicstability, intraope-rative awareness occurrence, and postoperative pain and anxiety.
Statisticalanalyses
In this study, the results of a descriptive analysis of the demographic data(age, weight,height, and BMI),gender andASAclassificationswereused.Thedatawassummarized usingthe meanand standard deviation.The Shapiro---Wilk testwasusedfor theassumptionofnormaldistributionof continuousvariables.Ifvariableswerenormallydistributed, central tendency wasexpressed asthe mean (SD).Means were compared using independent or paired Student’s
t-test. Spearmancorrelationanalysiswasusedtofindouta correlationbetweennon-normallydistributedindependent variables.Fisherexacttestwasusedforcategoricaldataand expressedincount,percentages.Differenceswere conside-redsignificantifp<0.05.Statisticalanalysiswasperformed usingSPSS22(Chicago,IL,USA).
Results
This study was carried out with 120 patients divided in twogroups of 60 people.There wasnostatistically signi-ficantdifferencebetweengroupsin termsofdemographic characteristics(age,BMI,gender, ASA)(p>0.05)(Table1). Theoperationperiodsofthegroupsweresimilar(p>0.05) (Table1).
ThemostpreferredmusicbyourpatientswasTurkishpop music (29 cases).Eastern and Western music were selec-tedby20and9patients,respectively.Theanesthesiologist chose classical music for 2 patients who did not show a particularpreference.
Whenthe valuesofMAP, SAPandDAPwerecompared, thedifferencesbetweenthetwogroupswerenot statisti-callysignificant(p>0.05),althoughthegeneralresultswere lowerinthemusicgroup.
WhenbothgroupswereevaluatedwithRSAS,theresults werelowerinthemusicgroup(3.76±1.64vs.5.11±2.13), which means that the patients in the music group had a betterawakeningquality(p<0.001)(Table2).
The mean VAS score for pain was lower in the music group, showing statistical significance (2.73±1.28 vs. 3.61±1.40)(p<0.001).Patientswithseverepostoperative pain(VAS≥5)weremedicatedwith0.5mg/kgPetidinHCL (Aldolan®)(4patientsofthemusicgroupvs.9ofthecontrol group)(Table2).
Patientsatisfactionrate wassignificantly higherin the music group (73.3% vs. 36.6%) than the control group (p<0.001)(Table2).
Theincidenceofintraoperativeawarenesswashigherin thecontrolgroup(4casesvs.9cases),butthedifference wasnotstatisticallysignificant(p=0.14)(Table2).
Discussion
Music therapy, a nonpharmacological modality; can be acceptedasaneffectivemethodintraoperativelyand post-operativelywhenappliedtoseptorhinoplastypatientsunder generalanesthesia. Inourstudy,we haveconcludedthat,
Table1 ComparisonofgroupMandgroupCbasedondemographicparameters,hemodynamicparametersandsurgical inter-ventionscharacteristics.
Variable GroupM(n=60) GroupC(n=60) p-Valueb
Age,mean±SDyearsa 31.93±8.67 31.56±8.05 0.81
Gender(male/female) 29/31 27/33 0.71
BMI,mean±SD(kg/m2)a 25.47±3.98 26.81±4.76 0.98
ASA-PSclass 0.14
ClassI 23(38.3%) 28(46.6%)
ClassII 37(61.6%) 32(53.3%)
Timeofsurgery,mean±SDa 139.75±9.75 141.03±10.8 0.49
Timeofanesthesia,mean±SDa 159.58±8.88 160.60±9.17 0.53
MAP,mean±SD(mmHg)a 85.13±10.43 86.66±10.78 0.578
HR,mean±SD(beat/min)a 78.56±9.66 79.63±13.84 0.730
ASA-PS,AmericanSocietyofAnesthesiologistPhysicalStatus;SD,standarddeviation;GroupM,musicintervention;GroupC,control group;MAP,meanarterialpressure;HR,heartrate.
a Valuesareexpressedasmean(SD). b Independentttest.
Table2 Effectsofmusictherapyonrecoveryquality,VASduringrecovery,patientsatisfactionandintraoperativeawareness.
Parameters GroupM(n=60) GroupC(n=60) pb
Rickerscale(qualityofrecovery)a 3.76±1.64 5.11±2.13 <0.001
<5 44(73.3%) 25(41.6%)
≥5 16(26.6%) 35(58.3%)
VASduringrecoverya 2.73±1.28 3.61±1.40 <0.001
<5 56(93.3%) 51(85%)
≥5 4(6.6%) 9(15%)
Patientsatisfaction 44(73.3%) 22(36.6%) <0.001
Intraoperativeawareness 4(6.6%) 9(15%) 0.14
VAS,visualanalogscale;GroupM,musicintervention;GroupC,controlgroup.
a Valuesareexpressedasmean(SD). b Independentttest.
the patients in the music therapy group hadbetter awa-kening quality(3.76±1.64 vs. 5.11±2.13; p<0.001) and lowerlevelofpainaccordingtoaVAS(visualanalogscale) (2.73±1.28vs. 3.61±1.40;p<0.001),and higherpatient satisfactionrates (73.3 vs. 36.6, p<0.001). We have also deducedthattheincidenceofHR(heartrate),SAP (systo-licarterialpressure),DAP(diastolicarterialpressure),MAP (meanarterialpressure)andintraoperativeawarenesswere lowerbutnotstatisticallysignificant.
Music therapy isone ofthe most effectivetherapeutic practices that draws attention of individuals from them-selvesandfromtheirproblemstoanotherdirection.Studies have shown that the relaxation quality of music is a non-invasivemethodthatreducesthephysiologicaleffects of stress suchasanxiety, blood pressure,heart rate, res-piration rate and improves the emotional state of the patients.13,16,17
Iftwoaudiblestimuliatdifferentfrequencies(1---30Hz) areapplied toboth earsat thesame time,theyare per-ceived as single warning. This warning is described as a brainstem reaction originating from the superior olivary nucleusinbothcerebralhemispheres,andthisresponseis thought to lead to a hemispheric synchronization. It has been suggestedthat hemisphericsynchronized sounds can be used for pain control, stress and anxiety treatment. RecordedCD’sforthispurposearecommerciallymarketed
worldwideunderthenameof‘‘nonpharmacologic surgical support’’.18 Inadditiontomusic therapy,hemispheric
syn-chronizedsounds werealsoinvestigatedfor effectsonBIS valuesinpatientsundergoinggeneralanesthesia,but hemis-phericsyncingdidnotaffectBISvaluesinpatientsreceiving generalanesthesia. More clinical trialsare neededin this regard.19
Bondoc et al.18 investigated the effect of
hemisphe-ric sound on perioperative analgesic requirement in the preoperativeandintraoperativeperiodsofpatients under-going general anesthesia. In this study, patients were randomlydivided intothree groups: hemispheric synchro-nized audiophiles, their favorite music tracks or empty cassettelisteners (control).Fentanylwasusedasan anal-gesic during induction and intraoperative period. In the hemisphericvoicegroup,therewaslessneed forfentanyl thaninthecontrolormusicgroup.Painleveland postope-rativeanalgesicrequirementwerelowerinthehemispheric groupthanintheothergroups.Ithasalsobeenfoundthat thedurationofstay untildischarge fromthe hospitalwas shortenedinthehemisphericvoicegroup.However,there wasnodifferencebetweenthegroupsintermsof intraope-rativeheart rate,blood pressurelevelsandpostoperative nausea,vomiting.Inourstudy,weadministered remifenta-nilinfusioninsteadoffentanylinfusionduringintraoperative analgesiaandweconcludedthatremifentanilconsumption
wassignificantlyreducedinthemusicgroup,similarlytothe studyofBondocetal.
Allen et al.20 reported that perioperative music
the-rapy reduced the stress-inducedhypertensive response in agroup ofgeriatric patients tobe undergoingophthalmic surgeries under local anesthesia. The heart rates, systo-lic and diastolic blood pressures of the patients listening to the music were found to be similar to those measu-redoneweekbeforesurgery. Inthisstudy,itwasthought that the reason for the positive effectin the hemodyna-micparameterswasthereductionoftheanxietyregarding thesurgery,byredirecting theattentionof thepatientto the music. In addition, it has been observed that music increasesthefeelingofpersonalcontrolinpatientsat post-operativeconditionsandthatitleads toa generalfeeling ofwell-being.Inourstudy,itwasobservedthat intraopera-tivemusicalstimulationreducedthelevelsofHR,SAP,DAP, MAPbutitwasnotstatisticallysignificantcomparedtothe controlgroup.Similarlytoourstudy,thereareotherstudies showingthatmusictherapyhasnoeffectonhemodynamic parameters.18,19,21
In an animal study carried out in order to explain theeffect of music therapy on hemodynamics,the music showedtoreducebloodpressureinhypertensiverats. Music-therapy applied to rats also showed that blood calcium levels increased, with consequent increase of dopamine synthesisinthebrainvia acalmodulin-dependent system. The increase in dopamine level is thought to decrease blood pressure by inhibiting sympathetic activity by D2 receptors.22 Based on these findings, it can be
postula-ted thatin diseases withdopaminergic dysfunction music therapy may be effective in relieving the symptoms. As a result of music therapy in Parkinson’s disease, positive developments have been reported in motor and emo-tional functions and also in daily activities.23 Similarly,
it has been observed that it relieved the symptoms of epilepsy.22
Ithasbeenreportedthatanxiolyticeffectsofmusicwere investigatedasa treatment modality in eliminating preo-perativeanxietyinanesthesiologypractice.11,24Minimizing
anxiety in the preoperative period facilitates the induc-tionofanesthesia,preventsundesiredreflexcardiovascular response,andreducestherequiredanestheticdoseby redu-cingoxygenconsumption.Inastudycomparingpreoperative musictherapywithmidazolamtreatment,thereductionin anxietyscorewithmusictherapywasfoundtobe significan-tlyhigherthanwithmidazolamtreatment.
Inordertoinvestigatetheeffectofmusiconanxietyin thepreoperativeperiod,99patientsundergoingdaysurgery, wererandomlydividedintomusicandcontrolgroups.None ofthepatientswerepremedicatedwithapharmacological agentfor sedation.Onthe dayofthesurgery,any kindof musicCDselectedandbroughtbypatientswaslistenedto 30min during thepreoperative period.Becausethe study wasdouble-blind,inthecontrolgroup,theCDplayerplayed ablankCD.Theanxietylevelsofthepatientswere evalua-tedwiththe40 itemState/TraitAnxiety Inventorybefore and after this application. In addition; measurements of serumcortisolandcatecholamine levelsbeing neuroendo-crine variablesof anxiety, blood pressures andheart rate being physiological indicators of anxiety were also per-formed simultaneously. As a result, it was observed that music therapy reduced anxiety, but did not affect hemo-dynamic parameters such as blood pressure, heart rate, andserumcortisolandcatecholaminelevels.10 Wedidnot
evaluatethe preoperative or postoperativeanxiety inour study.We used the Riker sedation agitationscale (RSAS), acommonly usedscale, tomeasure thelevel of
postope-rative sedationand concludedthatthesedation scores of thepatientsin themusicgroupwerehigherthanthoseof the controlgroup, similarlytoother studies in the litera-ture.
Koc¸etal.13foundthatmusictherapysignificantlyreduces
anxietyandBISvaluesandreportedthat,inadditiontothe needof lesssedativedrugsduringregionalanesthesia, lis-tening toclassicalTurkish music couldbea harmless,fun and low cost adjuvant. Music therapy has been shown to reducetheneedforpropofoltoprovideadequatesedation in patients withcontrolledsedationundergoing urological surgery (under spinal anesthesia). The authoralso obser-ved that music therapy decreased 44% of the need for opioid consumption in patientcontrolledanalgesia.25 It is
clearly known that postoperative pain causes undesirable clinical conditions such as metabolic and endocrine res-ponses,adverseeffectsonorganfunctions,musclespasms and atelectasis. For this reason, postoperative analgesia managementishighlyvital.Nilssonetal.12foundthatmusic
therapyreducedthepainandanalgesicdrugsrequirement. They studied 90 patients who underwent abdominal hys-terectomyundergeneralanesthesiarandomlydividedinto threegroups;music,therapeuticsuggestionwithmusicand controlgroup.Relaxingmusicaccompaniedbywavesounds waslistenedtothe musicgroup. The samemusic was lis-tened to the patients in therapeutic suggestion group in additiontoarelaxingandencouragingsuggestion.The sug-gestion was performed with a relaxing male voicetelling that there would be no post-operative pain, nausea and vomiting, recovery would be quick, while patients in the control group listened to a pre-recorded tape containing noises of an active operation room. The follow-up sho-wed that patientsin the music group presented less pain andanalgesicrequirements,andrecoveredearlierthanthe others.Inaddition,fatiguesensationatdischargewereless frequentlyobserved in thegroups ofmusic and therapeu-ticsuggestionwithmusic.However;musictherapydidnot reduce postoperative nausea and vomiting. In this study, asinourstudy,patient-controlledanalgesiawasusedasa routinetechnique inthe treatmentof pain,andsimilarly, theamountofanalgesic consumedinthemusicgroupwas found tobe lower. In addition,postoperative nausea and vomitinginourstudydidnotdifferbetweenthemusicand controlgroups.Also,weobservedthatinthemusicgroup, early postoperative parameters and sedation scores were positivelyaffected.
Inastudypublishedin1995at CHEST,twogroupswere established toinvestigate theeffect ofmusic on patients undergonebronchoscopy.The musicgrouphad21patients the controlgroup, 28 patients.It wasconcludedthat the rateofsatisfactionwashigherinthemusicgroup.26Another
similarstudyconsistedofpatientssubmittedtocolonoscopy under general anesthesia(85 patients in the music group vs. 81 patients in the control group). The rate of satis-faction in themusic group washigherthan inthe control group(96.3%vs.56.1%,respectively)p<0.0001.27Ina
meta-analysispublishedin2019,on8randomizedtrialsinvolving 712patientsundergeneralanesthesia,satisfactionwas sig-nificantly higher in the music group.28 In addition, other
studies have confirmed thatmusic has positive effectson patientsatisfaction.29,30
Finally, in our study, we examined the incidence of intraoperative awareness with music therapy. In a study thatMohamedKahlouletal.,31theyexamined140patients
whounderwentabdominalsurgeryundergeneral anesthe-sia.Patientsweredividedin2groups of70patients,with andwithoutmusictherapy.Patientswithoutmusictherapy presented significative more episodes of intraoperative
awareness. In our study, the incidence of intraoperative awareness was higher in the control group (4 patients in themusicgroupvs.9patientsinthecontrolgroup)butnot statisticallysignificant(p>0.05).
Conclusion
Wehavefoundthatmusictherapydecreasesthepainlevel and the need of analgesic drugs intake intraoperatively and postoperatively. In addition, we showed that it has positive effects onpostoperativeparameters andlevel of sedation. In conclusion, we have shown that music the-rapy is a non-pharmacologicalmethodwith practicallyno costs,easy-to-apply,withoutsideeffects,thatincreasesthe sedationandreducespainlevels,asobservedinprevious cli-nicaltrials.However,theexperienceonthissubjectisstill verylimiteddespite theincreasingnumberoftrials.More effortsareneededtoensurethatmusictherapygainsamore respectableand distinct place in themodern health care system.There isalsoaneed forprospectiveclinical trials involving more patients, multicentered, double-blinded, randomizedandcontrolled,withbloodtestsinvestigation. Wealsothinkthathumanandanimalstudieswouldbe use-fultodefinethedifferentmechanismsofactionthatwould explainthepositiveeffectsofmusictherapy.
Funding
Thestudywasfundedbydepartmentalresources.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Flanagan DA, Kerin A. How is intraoperative music therapy beneficialtoadultpatientsundergoing generalanesthesia?A systematicreview.AnesthesiaJ.2017;5:5---13.
2.NilssonU.Theanxietyandpain-reducingeffectsofmusic inter-ventions:asystematicreview.AORNJ.2008;87:780---807. 3.Shafer A, Fish MP, Gregg KM, Seavello J, Kosek P.
Preo-perative anxiety and fear: a comparison of assessments by patientsand anesthesia andsurgeryresidents.Anesth Analg. 1996;83:1285---91.
4.BiebuyckJFWC.Themetabolicresponsetostress:anoverview andupdate.Anesthesiology.1990;73:308---27.
5.DesboroughJP.Thestressresponsetotraumaandsurgery.BrJ Anaesth.2000;85:109---17.
6.Kayhan Z. Clinic anesthesia 3.Edition Istanbul. Logos Publ. 2004;6:16---36.
7.AllredKD,ByersJF,SoleML.Theeffectofmusicon postopera-tivepainandanxiety.PainManagNurs.2010;11:15---25. 8.BuffumMD,SassoC,SandsLP,LanierE,YellenMHA.Amusic
interventiontoreduceanxietybeforevascularangiography pro-cedures.JVascNurs.2006;24:68---73.
9.FischerSP,BaderAMSB.Preoperativeevaluation.In:MillerRD, editor.Miller‘sanaesthesia.7thed.ChurchillLivingstone: Phi-ladelphia;2008.Chapter34.
10.Wang S, Kulkarni L, Dolev J, Kain Z. Music and preopera-tiveanxiety: a randomized, controlled study.Anesth Analg. 2002;94:1489---94.
11.Bringman H, Giesecke K, Thörne A, Bringman S. Relaxing music as pre-medication before surgery: a
randomi-sed controlled trial. Acta Anaesthesiol Scand. 2009;53: 759---64.
12.Nilsson U, Rawal N, Uneståhl LE, Zetterberg C, Unos-son M. Improved recovery after music and therapeutic suggestions during general anaesthesia: a double-blind ran-domised controlled trial. Acta Anaesthesiol Scand. 2001;45: 812---7.
13.Koc¸H,ErkG,Apaydın Y,HorasanlıE,Yi˘gitbaG¸ıBDB.Epidural anesteziilehernioperasyonuuygulananhastalardaklasiktürk müzi˘gininintraoperatifsedasyonüzerineetkileri. TürkAnest ReanDerDerg.2009;37:366---73.
14.MuirWW,RobertsonJT,KbBA,FerragutR,UnidadCM, Intensi-vosC,etal.ProspectiveevaluationoftheSedation-Agitation Scale for adult critically ill patients. Colomb J Anesthesiol. 2012;4:293---303.
15.AuquierP,PernoudN,BruderN,SimeoniM-C,AuffrayJ-P, Cola-volpeC,etal.Developmentandvalidationofaperioperative. Anesthesiology.2005;102:1116---23.
16.MigneaultB,GirardF,AlbertC,ChouinardP,BoudreaultD, Pro-vencherD,etal.The effectofmusicontheneurohormonal stress response to surgery under general anesthesia. Anesth Analg.2004;98:527---32.
17.CookJD.Thetherapeuticuseofmusic:aliteraturereview.Nurs Forum.1981;20:252---66.
18.Dabu-BondocS,NadiveluN,BensonJ,PerretDKZ.Hemispheric synchronizedsoundsandperioperativeanalgesicrequirements. AnesthAnalg.2010;110:208---10.
19.Dabu-Bondoc S, Drummond-Lewis J, Gaal D, McGinn M, Caldwell-Andrews AAKZ. Hemispheric synchronized sounds and intraoperative anesthetic requirements. Anesth Analg. 2003;97:772---5.
20.Allen K, Golden LH, Izzo JL, ChingMI, Forrest A, Niles CR, et al.Normalization ofhypertensiveresponsesduring ambu-latorysurgicalstress byperioperative music.PsycosomMed. 2001;63:487---92.
21.NilssonU,RawalN,EnqvistB,UnossonM.Analgesiafollowing musicand therapeuticsuggestionsinthePACUinambulatory surgery:arandomizedcontrolledtrial.ActaAnaesthesiolScand. 2003;47:278---83.
22.Sutoo D, Akiyama K. Music improves dopaminergic neu-rotransmission: demonstration based on the effect of music on blood pressure regulation. Brain Res. 2004;1016: 255---62.
23.Pacchetti C, Mangini F, Aglieri R, Fundaro CMENG. Active musictherapyinParkinson‘sdisease:anintegrativemethodfor motorandemotionalrehabilitation.PsychosomMed.2000;62: 386---93.
24.TwissE,SeaverJ,McCaffreyR.Theeffectofmusiclisteningon olderadultsundergoingcardiovascularsurgery.NursCritCare. 2006;11:224---31.
25.Koch ME, Kain ZN, Ayoub CRS. The sedative and anal-gesic sparing effect of music. Anesthesiology. 1998;89: 300---6.
26.Dubois JM, Bartter T, Pratter MR. Music improves patient comfort level during outpatient bronchoscopy. Chest. 1995;108:129---30.
27.BechtoldML,PerezRA,PuliSR,MarshallJB.Effectofmusicon patientsundergoingoutpatientcolonoscopy.WorldJ Gastroen-terol.2006;12:7309---12.
28.BechtoldML, PuliSR, OthmanMO,Bartalos CR, MarshallJB, RoyPK.Effect ofmusicon patientsundergoing colonoscopy: a meta-analysis of randomizedcontrolled trials.DigDis Sci. 2009;54:19---24.
29.Bradley Palmer J, Lane D, Mayo D, Schluchter M, Leeming R. Effects of musictherapy onanesthesia requirements and anxiety in women undergoing ambulatory breast surgery for cancerdiagnosisandtreatment:arandomizedcontrolledtrial. JClinOncol.2015;33:3162---8.
30.Jayaraman L, Sharma S, Sethi N, Jayashree S, Kumra VP. Doesintraoperativemusictherapyorpositivetherapeutic sug-gestions during general anesthesia affect the postoperative outcome?Adoubleblindrandomisedcontrolledtrial.IndianJ Anaesth.2006;50:258---61.
31.KahloulM,MhamdiS,NakhliMS,SfeyhiAN,AzzazaM,Chaouch A, et al. Effects of music therapy under general anesthe-siain patientsundergoing abdominalsurgery. LibyanJ Med. 2017;12:1260886.
