The perioperative period is not only physically traumatic, it is also a source of significant fear and anxiety for patients (1,2). Therefore, anxiolytic drugs and sedatives are regularly administered, before and during surgery, for the purpose of calming patients. Still, the ambulatory setting often prevents the optimal use of these drugs. Patients are often seen just before surgery, making it impractical to administer premedication and, because of the emphasis on early discharge, anesthesiologists may choose to withhold sedatives during surgery. Finding a nonpharmacologic alternative suitable for alleviating the anxiety experienced by patients having surgery under regional anesthesia may then seem worthwhile. Authors have already suggested that music can be used to reduce the anxiety associated with many situations experienced during a hospital stay (3–9). Still, most of these studies did not focus on patients having ambulatory or short-stay surgery, particularly under spinal anesthesia. Moreover, these studies did not assess how the anxiolytic effect of music compares with the administration of sedative drugs.
The primary goal of this study was to measure the influence of music on sedative requirements and hemodynamic values and to compare the anxiolytic effects of music and self-administered midazolam in patients undergoing ambulatory or short-stay surgery under spinal anesthesia. The secondary goal was to evaluate the correlation between two well known measures of anxiety, Spielberger’s State-Trait Anxiety Inventory test (STAI) and the 0- to 10-cm visual analog scale (VAS 0–10), in this context.
After approval from our Institutional Research and Ethics Committees, 50 adult patients, ASA I or II, scheduled to undergo nononcologic surgery under spinal anesthesia provided written, informed consent before being enrolled in this prospective, randomized study. All participants were either outpatients or were scheduled to spend the night after surgery in the short-stay unit. Parturients, patients experiencing mental illness or documented hearing loss, and those taking drugs likely to influence their mood or hemodynamic status were excluded. Unpremedicated participants were randomly divided in two groups: patients allowed to listen to music through a headset during the perioperative period (Group I) and those not permitted to do so (Group II). Immediately after their inclusion in the study, while they were still on the preoperative ward, all participants completed both parts of the STAI questionnaire (Evaluation 1). The STAI is composed of two distinct forms, the Trait Anxiety Inventory (STAI-TA) and the State Anxiety Inventory (STAI-SA) scores (10). The former measures basic anxiety, providing stable data, and the latter evaluates anxiety that can be induced or modified by changes in the environment. Participants were also asked to evaluate their anxiety level on the VAS 0–10, with 0 meaning complete relaxation and 10 the worst feeling of anxiety possible. Arterial blood pressure, heart rate, and respiratory frequency were also noted.
Sixty minutes before entering the operating room (OR), patients were brought to the preoperative waiting area, where they completed a second STAI-SA form and evaluated their anxiety level (VAS 0–10) (Evaluation 2). Arterial blood pressure, heart rate, and respiratory frequency monitoring was then initiated, and values were noted every 5 min until the end of the study. The IV administration of lactated Ringer’s solution was started (200 mL/h), and a patient-controlled sedation device (PCS; Graseby Medical, Hertz, England) was made available to all participants. The PCS was set to deliver 0.25 mg midazolam as often as every 5 min with no programmed maximum cumulative dose. All patients were instructed about the proper use of the PCS device and the anxiolytic properties of its content. Patients in Group I were then given a nonocclusive headset that allowed them to listen to the music of their choice from multiple tracks prepared by the authors. The tracks included a wide selection of artists and genres (pop, jazz, classical, and new age). The volume of the music was set by the participants. Five minutes before entering the OR, all participants were asked for a third time to fill out a STAI-SA form and rate their anxiety level (VAS 0–10) (Evaluation 3). In the room, spinal anesthesia was achieved after the administration of 10–15 mg 0.75% hyperbaric bupivacaine. If needed, 5 mg ephedrine and 25-μg fentanyl boluses could be administered to correct hypotension and inadequate anesthesia. Thirty minutes after their arrival to the recovery room, patients were asked to complete the STAI-SA questionnaire and rate their anxiety on the VAS 0–10 for the last time (Evaluation 4). They were then allowed to keep the PCS device and the music-playing device (Group I) until recovery from the motor block. Patients were cared for by different surgical and anesthesia teams, but in each case, a nonblinded observer, either one of the authors (CL) or a specially trained nurse, supervised the research procedure.
Demographic and surgical data were analyzed with the Fisher’s exact test and Student’s t-tests. Hemodynamic and respiratory data and midazolam requirements were compared with the Student’s t-test followed with Bonferroni’s correction. Values obtained with the STAI-SA and VAS 0–10 were compared between groups with repeated-measures analysis of variance. STAI-SA and VAS 0–10 scores were also plotted against each other with linear regression, and the correlation between them was estimated using Spearman’s coefficient with a 95% confidence interval (CI). Unless stated otherwise, values are presented as mean ± sd. Statistical significance was assumed for P < 0.05.
There was no difference between groups with regard to demographic and surgical data, except for mean duration of surgery, which was longer in Group I (Table 1). There was no difference between groups with regard to systolic blood pressure, heart rate, or respiratory frequency during the study. Table 2 shows that all the anxiety measurements (STAI-TA, STAI-SA, and VAS 0–10) were similar at the beginning of the study (Evaluation 1). Perioperative and total midazolam requirements were smaller in Group I (Table 3) compared with Group II. Two patients, both in Group II, received 25 and 50 μg fentanyl for mild discomfort.
Figures 1 and 2 show that measures of STAI-SA and VAS 0–10 obtained for the four evaluations (1, preoperative ward; 2, 60 min before surgery; 3, 5 min before surgery; and 4, 30 min after arrival to the recovery room) exhibited no difference between groups. Figure 3 represents linear regression obtained from plotting STAI-SA and VAS 0–10 scores for the four evaluations. Spearman’s coefficient values between STAI-SA and VAS 0–10 scores for the four evaluations ranged from 0.53 (95% CI, 0.37–0.76) to 0.68 (95% CI, 0.50–0.81) (Fig. 3).
This study found that patients who listened to music required less midazolam to achieve the same level of anxiety (or relaxation) than control patients. It suggests that perioperative anxiety can be managed equally whether we opt for listening to music or for using larger dosages of anxiolytic drugs.
Ambulatory or short-stay surgery is a significant source of stress for many reasons. The perioperative anxiety level can be influenced by two major factors: the patient’s ability to tolerate stress, and fear of the relative unknowns of anesthesia and surgery (3). Patients can be very frightened and still be reluctant to communicate their fear to busy practitioners (11). Patients are not only anxious about anesthesia and surgery, but they also experience feeling isolated in an unfamiliar environment. While they are awake in the OR, patients face numerous visual and auditory stimuli. They hear what is perceived as technical, unintelligible language and they fear losing control of their bodies and being overcome by pain. Faced with these emotions, many patients will enter a state of regression. It is suggested that music can then act as a nonverbal link, allowing communication of the patient’s emotion (11). Listening to music can modulate the human’s response to stress (3,9), and studies have suggested that music can be used as an adjunct during therapeutic interventions (8,12). It is also an attractive option from an economic standpoint. In a study conducted during laceration repair in an emergency department, Menegazzi et al. (13) emphasized how inexpensive the adjunct of music is, because cassettes and CDs are easily stored and have a long shelf-life. They also demonstrated that music can reduce the pain reported by patients. It is then conceivable that it could also help to decrease analgesic requirements. To measure the economic potential of music as a drug substitute or adjunct, one would have to evaluate not only the reduction in drug requirements, but also the effect of such a reduction on other areas of the perioperative experience. Can music, or smaller dosages of sedative, decrease the length of the hospital stay? Could less-sedated patients be able to leave sooner, thus decreasing the burden imposed on postoperative resources? Can the economy achieved by decreasing self-injected midazolam requirements be duplicated if anesthesiologists are in charge of its administration? All these topics will need further studies.
For it to contribute to anxiety reduction, the music selected should exhibit certain specific characteristics. It should be chosen by the patient, because personally selected music seems more likely to reduce autonomic reactivity, as opposed to an experimenter’s selection (14). Tracks should be mixed to convey a continuous and homogeneous ambience. Finally, the tracks and playing device should be of good quality, thus avoiding auditory fatigue (11).
Few authors have studied the effect of music during surgery under regional anesthesia. Cruise et al. (8) assessed the effect of music on elderly patients undergoing cataract surgery under retrobulbar block. They reported that patients were more satisfied with the “whole operative experience” if they heard music rather than relaxing suggestions, white noise, or OR noise. However, the authors did not find that music influenced STAI-SA results in those patients. They did not study the influence of music on sedative requirements, because midazolam, fentanyl, and alfentanil were administered at predetermined dosages by the anesthesiologist in charge. We elected not to report on patient satisfaction in this study, because it has been suggested that most available scales designed to measure it during the perioperative period were inadequate because they did not allow for control of confounding variables, such as social desirability (15). Koch et al. (16) were the only authors to report on the effect of music during spinal anesthesia. They studied a smaller (n = 34), older (mean age, 54 years), and more predominantly male (86%) group of patients than we did. All participants underwent urologic procedures. Although they used a different sedative (propofol), their study, like this one, showed that patients listening to music required smaller amounts of sedatives than patients in the control group. Still, because the authors did not measure the anxiety level of participants, they could not conclude that propofol and music provided similar anxiety control in both groups during the perioperative period. Also, because they used occlusive headsets, the authors stated that they could not conclusively ascribe their results to intraoperative use of music. They believed that they could not rule out the elimination of ambient OR noise as a cause for decreased sedative requirements. We elected to use a nonocclusive headset so that patients would be able to hear and communicate with the anesthesiologist or surgeon throughout the surgery and perioperative period. Although it is still possible that the reduction of ambient noise was contributory to decreased midazolam requirements in this study, it seems unlikely that it was the main explanation for it.
Although STAI and VAS 0–10 scores are both used to measure anxiety (5,6,8,16), only the STAI has been developed with the necessary rigor and subjected to proper psychometric evaluations (test-retest correlation and reliability and validity testing). Total scores for situational (STAI-SA) and baseline (STAI-TA) anxiety separately range from 20 to 80, with higher scores denoting higher anxiety. One of the goals of this study was to evaluate the correlation between the VAS 0–10 anxiety scale, an instrument easy to use but untested, and the STAI. This study showed that, even if STAI and VAS 0–10 scores are positively correlated, the strength of this correlation is only moderate. Therefore, researchers should be cautious when comparing results between studies that use these different tools.
In conclusion, this study shows that listening to music throughout the perioperative period is associated with decreased midazolam requirements in patients undergoing ambulatory or short-stay surgery with spinal anesthesia. It also shows that anxiety can be satisfactorily controlled whether patients use music or self-administered midazolam.
The authors wish to thank Christiane Côté, BSc, for her assistance in the data collection for this work.
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