Implementation of Music as anAnesthetic Adjunct During Monitored

Anesthesia CareAshley Newman, MSN, CRNA, Christie Boyd, MSN, CRNA, Debbie Meyers, DNP, CRNA,

Laura Bonanno, DNP, CRNA

Operating room sounds and music can be influential on a patient’s expe-

Ashley Newman

Medical Center, Co

is a CRNA, Touro

DNP, CRNA, is a CR

Center, Baton Rou

ing Program Direc

Sciences Center, Ne

Address corresp

D. Wood Road, Fr

.lanell@gmail.com

� 2010 by Ame

1089-9472/$36.

doi:10.1016/j.jo

Journal of PeriAnesth

rience, especially duringmonitored anesthesia care (MAC). In this article,

the effect of music and noise on patients during MAC was assessed. The

Bispectral Index (BIS) Monitor was used to evaluate the effect of music

on the level of sedation or anesthesia in the articles reviewed. A review

of current literature was completed regarding the use of music in the

OR during MAC cases and its relationship to propofol sedation require-

ments. Ten journal articles were reviewed with publication dates ranging

from 1997 to 2009. The use of music as an anesthetic adjunct during

MAC cases can reduce the amount of sedation required, speed recovery

time, and prevent the likelihood of converting to a general anesthetic.

Keywords: music, noise, monitored anesthesia care, BIS, propofol.

� 2010 by American Society of PeriAnesthesia Nurses

IN THE OR SETTING, sound, in varying capac-

ities, has a profound impact on patients that ranges

from a therapeutic effect to a disruptive, unpleas-ant experience. The two sounds of particular inter-

est to anesthesia providers and other health care

workers are music and noise. In the literature,

noise has been described as ‘‘unwanted sound.’’1

Music ranges across all genres depending mainly

on the surgeon’s preference. Currently during

monitored anesthesia care (MAC) cases, there is

no set protocol that addresses sound level in theOR or its acknowledged effect on the patients.

, MSN, CRNA, is a CRNA, Doctor’s Regional

rpus Christi, TX; Christie Boyd, MSN, CRNA,

Infirmary, New Orleans; Debbie Meyers,

NA, Our Lady of the Lake Regional Medical

ge; and Laura Bonanno, DNP, CRNA, is Act-

tor, Nurse Anesthesia Program, LSU Health

w Orleans, LA.

ondence to Ashley Newman, 22170 John

anklinton, LA 70438; e-mail address: ash

.

rican Society of PeriAnesthesia Nurses

00

pan.2010.10.003

esia Nursing, Vol 25, No 6 (December), 2010: pp 387-39

In recent years, the definition of MAC has been re-

vised to clearly delineate between sedation, MAC,

and general anesthesia. According to Barash et al,2

‘‘MAC may or may not involve the provision of se-

dation ranging from minimally depressed level of

consciousness to deep sedation.’’ According to

the American Society of Anesthesiologists,3 ‘‘if

the patient loses consciousness and the ability to

respond purposefully, the anesthesia care is a gen-

eral anesthetic, irrespective of whether airway

instrumentation in required.’’ When adhering tothese professional guidelines set for MAC cases, pa-

tients retain the sense of hearing throughout the

surgical procedure. For this reason, the effect of

noise and music is especially important for anesthe-

sia providers to understand so that they can serve as

patient advocates to improve quality of care.

Purpose

The purpose of this article is to provide the

evidence needed for perioperative health care pro-fessionals, especially anesthesia providers, to eval-

uate both the need for and effectiveness of

therapeutic music as an adjunct to the anesthetic

1 387

388 NEWMAN ET AL

plan. This literature review compiled studies as-

sessing the relationship of music to the anesthetic

outcomes of patients undergoing a variety of surgi-

cal procedures.

Background

The Environmental Protection Agency recom-

mends that sound levels in a health care setting

should not exceed 45 dB; however, in everydayclinical practice settings, sound levels are actually

double the recommended level.4 In orthopedic

surgical cases, the noise level in the OR can actu-

ally be even greater simply because of the instru-

ments required for these procedures. Although

this is not a new topic, the effect of OR noise levels

is beginning to gain interest, and further research

is being conducted on how noise levels affect pa-tient care.4 Researchers have determined that noise

can be a detriment to patients, creating conditions

of hypertension, tachycardia, and even decreased

wound healing.4 In a study conducted on neonates,

oxygen saturation decreased when the neonates

were subjected to increased noise levels.1,4 During

surgery, the patient is completely vulnerable to his

or her circumstances. The level of noise patientsendure in an OR is multifactorial and includes

alarms, cell phones, staff communication, surgical

instruments such as drills, and intercom an-

nouncements. This combination is antagonistic to

a therapeutic anesthesia experience. Although

many of these sounds are inevitable, it is the

anesthesia provider’s responsibility as a patient

advocate to control the noise level as much aspossible.1,4

The history of music in health care dates as far

back as the sixth century, when Greek philoso-

pher Pythagoras began prescribing music as a res-

toration of the mind and body’s natural harmony.

By the mid-1800s, the therapeutics of music began

receiving more recognition as Florence Nightin-gale observed the positive effect of harmonic and

continuous sounds from wind instruments. With

the invention of the phonograph in the late

1800s, music was first played in the health care set-

ting and gained in popularity until 1914, when in-

traoperative music was provided to help ‘‘distract

patients from the horror of surgery.’’5 In the early

to mid-1900s, the National Association of Musicin Hospitals was formed by a nurse advocating

for musical prescriptions, and a group of surgeons

conducted independent research on the psychoso-

matic factors of music and noted that their patients

experienced a much calmer surgery, which had

not been provided by medications in the past.5

The cause and effect of music during surgery is still

not fully understood.5 The central concept revolves

around the belief that hearing remains intact even

when a person is suspended between sleep and

consciousness. It has been proposed that music

stimulates brain functions engaging memory, learn-

ing, and numerous motivational and emotional

states.5 According to Dr Lawrence Parsons of theUniversity of Texas–San Antonio, ‘‘The research

shows more clearly than ever that music is repre-

sented in mechanisms widely distributed through-

out the brain rather than localized in a single

region as are other kinds of information, such as

visual or movement information.’’6 Dr Thaut,7 pro-

fessor of music and neuroscience, hypothesized

about the pathway of music throughout the brain.His theory states that auditory recognition of music

occurs in the temporal lobe’s auditory center,

which stimulates the thalamus, midbrain, pons,

amygdale, medulla, and hypothalamus.

In the research reviewed, the Bispectral Index

Monitor (BIS) is the most commonly used brain

wave or brain function monitor. It is used as a mea-surement tool to evaluate the effect of music on

the level of anesthesia. The use of brain wave mon-

itoring is gaining popularity among anesthesia pro-

viders and many believe it will one day become

a standard of care. A BIS is a neurophysiological

monitoring device used to assess a patient’s level

of consciousness during anesthesia by analyzing

an electroencephalogram (EEG). The ‘‘depth ofanesthesia’’ is commonly used to determine a pa-

tient’s surgical awareness. ‘‘BIS has been found to

be useful when monitoring recall during con-

scious sedation with propofol.’’8

The BIS monitor is an electroencephalogram-

derived multivariant scale that correlates with

the metabolic ratio of glucose.9 From this meta-bolic activity, the brain obtains its functionality,

the ability to capture information from outside

and inside the body, and integrate that information

into conscious perception, with the ability to re-

member it later. Both loss of consciousness and

awakening from anesthesia are correlated with

this scale.10 The BIS provides a valued number

IMPLEMENTATION OF MUSIC 389

that ranges from 0 to 100. A BIS value of 0 equals

EEG silence, near 100 is the expected value in

a fully awake adult, and between 40 and 60 indi-

cates a level for general anesthesia recommended

by the manufacturer. During MAC cases, a BIS of60 to 80 is normally desired.

BIS measurements assist in determining the exact

type and dose of anesthetic or sedative medication

to be administered for individual patients. All pa-

tients react differently to anesthesia. BIS monitor-

ing can be helpful in patients whose responses

are less predictable, including: geriatric and pediat-ric patients, frail patients, patients undergoing

lengthy surgeries, and patients with conditions

known to respond poorly to the administration

of anesthetics. The BIS monitor has demonstrated

its use as a valuable tool that, when used in con-

junction with standard anesthesia monitors, can

be relied upon to individualize patient care, includ-

ing measuring the effect of a music adjunct to care.

Review of Literature

A review of current literature was completed re-

garding the use of music in the OR during MACcases and its relationship to propofol sedation re-

quirements. Ayoub et al11 found that ‘‘the music

group required significantly less propofol as com-

pared with the two other study groups (white

noise/sound machine or operating room noise);

p 5 0.026.’’ Authors also found that ‘‘significantly

more participants from the music group did not re-

quire any propofol intraoperatively comparedwith the other two study groups described above;

p5 0.01. Participants in the music group required

less propofol at both centers.’’11

Music has been shown to reduce a patient’s anxi-

ety level and decrease sedation requirements. In

a study of 110 American Society of Anesthesiolo-

gists (ASA) I and II women, aged 24 to 59, undergo-ing elective total abdominal hysterectomy using

combined spinal epidural anesthesia, researchers

determined that music benefitted the patients by

reducing sedation requirements and overall anxi-

ety.12 No premedication was given to any partici-

pants, and each was randomized by computer to

either the music or no-music group. Patients in

the music group had a significant reduction inthe mean induction time of sedation with propofol

infusion, as well as a decrease in overall propofol

sedation requirements throughout the procedure.

As with the Ayoub study, these researchers

demonstrated that music helps patients achieve

a level of sedation that is adequate and that re-

quires a lower dosage of propofol, reduction intime to induction of sedation, and increase in pa-

tient satisfaction.12 Dae et al13 also found a signifi-

cant reduction in the propofol requirements with

the use of noise reduction and music.

Andrada et al14 executed a study on anxiety during

the performance of colonoscopieswith amodifica-

tion using music therapy. The study included 118patients who were scheduled for ambulatory co-

lonoscopies. They were randomly assigned to the

control group (n 5 55) and the experimental

group (n 5 63). The patients’ level of anxiety

was determined by using the State-Trait Anxiety

Inventory Test (STAI) form, which they filled in be-

fore and after the examination. Patients listened to

music through personal headphones. The studyconcluded that listening to music during ambula-

tory colonoscopies, without the aid of other anxi-

olytic methods, decreases the level of anxiety that

is inherent to the process.14

Yilmaz et al15 executed a study to evaluate the

efficacy of music on sedation in extracorporeal

shock wave lithotripsy (ESWL) treatment to com-pare its anxiolytic effects with those of midazolam.

The population of the study included 98 urolithia-

sis patients whom were randomly divided into

two groups. For the hemodynamic parameters,

a statistically significant decrease in mean arterial

pressure was noted at the end of the ESWL proce-

dure in group 2 and in oxygen saturation from the

tenth minute to the end of the treatment in group1. Although the visual analog scale, Observer’s As-

sessment of Alertness/Sedation Scale, and STAI test

did not show statistically significant differences,

the STAI score was found to be lower in the music

group (group 2) than in the midazolam group

(group 1). The study concluded that with the anxi-

olytic effects of music, ESWL can be performed

more effectively with the patient in a comfortablestate. Listening to music by patients during the

ESWL session is a feasible and convenient alterna-

tive to sedatives and anxiolytics.15

Maeyamaet al16 executed a studyon the effect of the

use of music therapy under spinal anesthesia. The

aim of this study was to assess the use of music

Table 1. Sample Protocol for MAC Cases

� Include patient’s musical preference during

preoperative interview

� Apply BIS before anesthetic administration

� Initiate preferred music genre

� Titrate anesthetics to obtain BIS 60–80

� Accurately record amount of anesthetic administered

� Continue playing music until patient’s time in the

intraoperative setting is complete

BIS, Bispectral Index Monitor.

390 NEWMAN ET AL

therapy to reduce anxiety in patients under spinal

anesthesia using BIS and an interview-type psychol-

ogy test, STAI. Fifty-eight ASA physical status I to II

patients scheduled for spinal anesthesia were ran-

domly allocated into M group (music group, n 529) or C group (control, n5 29). BIS, electromyog-

raphy (EMG), and signal quality index (SQI) of both

groups were obtained continuously with a com-

puter system. Patients in the M group listened to

music with headphones and those in the C group

were left free under the ordinary OR environment.

The study concluded that music therapy reduced

the BIS value andwas effective in reducing patients’anxiety during spinal anesthesia.16

A study of 54 patients by Ganidagli et al17 evalu-

ated the effect of music during midazolam admini-

stration. BIS levels were recorded and were

significantly decreased in patients listening to

music versus patients only receiving medication.

Ayoub et al11 found that OR noise was associatedwith higher dosages of propofol compared with

dosages administered while there was music.

Benefits to Clinical Practice

Many anesthesia providers believe that noise in the

ORmay interferewith the ability to achieve a stable

level of sedation for patients undergoing surgical

procedures with local anesthesia as part of a moni-

tored anesthesia care technique. This review of

literature provides sufficient background on the

identified problem of noise level and the benefits

of using music in the OR. Current studies demon-strate how auditory input canmodulate the human

response to stress. The literature identifies factors

that can increase stress levels, which may be atten-

uated by the distracting and calming effects of mu-

sic. In fact, the literature did not reveal that music

had any negative effects on the level of sedation. If

music has been repeatedly associated with physio-

logical benefit in the OR, why is music not rou-tinely used for this purpose?

Music provides a calming and soothing effect for

patients, which prevents activation of the sympa-

thetic nervous system, leading to increased cate-

cholamine release.1,5 In the practice of most

anesthesia providers, medication is administered

to attenuate, or blunt, these adverse effects.Although medication is effective, the adverse

effects that can accompany higher dosages of

anesthetic agents cannot be overlooked. The use

of BIS monitoring and music in conjunction with

propofol, or other anesthetics such as versed or

fentanyl, for MAC cases can reduce the amount ofmedication required to keep the patient sedated

with maintenance of reflexes such as lid reflex,

gag reflex, and purposeful reactions to verbal

and physical stimulation.2,4 This approach can

help prevent the ‘‘deep MAC,’’ in which airway

obstruction requires intervention. In many cases,

the decrease in the amount of anesthetics used

can allow patients to bypass Phase I recovery andreturn directly to their inpatient room or the

same-day surgery room. With the use of the BIS

and music as adjuncts, anesthesia providers can

reduce the number of untoward events, prevent

conversions to a general anesthetic, and speed

the time to recovery. This leads to faster turnover

times between cases, increased overall productivity,

and improved patient safety.

Evidence-based research supports the use of music

in the OR during MAC cases to reduce the sedation

requirements of anesthetics. The use of music

and brain function monitoring during MAC cases

demonstrates a positive impactwith individualized

medication dosages maintained at a minimum

forpatients. The useofmusic ismost beneficial dur-ing induction and maintenance of MAC anesthesia

to decrease the dose of sedatives used, and to atten-

uate the stresses that noise can bring to the patient.

Direction for Future Research

The subject of sound in the OR is evolving into an

intriguing issue, but many areas are yet to be ex-

plored. Although numerous studies have been

done involving the calming effects of music, little

evidence exists regarding the type of music that

is better suited for therapeutic environments.

IMPLEMENTATION OF MUSIC 391

Questions are posed such as, ‘‘Does a patient’s per-

sonal preference of music improve their relaxa-

tion?’’ or ‘‘Does one type of music genre, such as

classical, evoke deeper anesthesia?’’ Other related

areas of focus might include the equipment play-ing the music: ‘‘Is there a difference between lis-

tening via personal headphones and listening to

the music played through OR speakers?’’ Regard-

ing noise levels in the OR, further research needs

to evaluate more closely the decibel level of noise

and at what level there is a change in patients’ BIS

levels. MAC cases routinely involve higher BIS

readings,10 but at what level does a person losethe sense of hearing?

Conclusion

As science provides more sophisticated technology,

sound will become even better understood and en-

able anesthesia providers to reach a more holistic

level of care during MAC cases that will improve

patient satisfaction and safety. It is important to ac-

knowledge the existing literature and begin imple-

menting changes in the OR environment that will

align anesthetic care with the direction of modernmedicine. The use of music as an anesthetic adjunct

during MAC cases can reduce the amount of seda-

tion required, speed recovery time, and prevent

the likelihood of converting to a general anesthetic.

References

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