Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 8  |  Issue : 4  |  Page : 580-584

Impact of intraoperative music therapy on the anesthetic requirement and stress response in laparoscopic surgeries under general anesthesia


1 Department of Anesthesiology, Smt. Kashibai Navale Medical College and General Hospital, Narhe, India
2 Department of Emergency Medicine, Dr D.Y. Patil Medical College and Hospital, Pimpri, Pune, India

Date of Submission26-Jan-2015
Date of Acceptance27-Jun-2015
Date of Web Publication29-Dec-2015

Correspondence Address:
N Patil Kalyani
B12, Manasi Apartments, Behind Suvarnayug Sahakari Bank, Bibwewadi, Pune 411037
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.172744

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  Abstract 

Context
Anxiety and pain are common responses to surgery and can negatively affect patient outcomes. Music is increasingly being used as a nonpharmacological intervention perioperatively, to improve patient outcomes and to avoid polypharmacy.
Aims
The aim of this study was to evaluate the impact of intraoperative music on the anesthetic requirement and stress response for laparoscopic surgeries under general anesthesia.
Settings and design
This was a prospective, randomized, double-blinded study.
Materials and methods
After approval of the hospital ethical committee, 60 ASA I patients were randomly assigned to the music and the no-music group. In the music group, classical instrumental music was played after the induction of anesthesia until the skin closure. In the no-music group, patients wore headphones but no music was played. We established three sample times for measurement of capillary blood sugar level during the procedure and one in the recovery room. Hemodynamic data were recorded. There was no statistically significant difference with respect to demographic profile, baseline hemodynamic variables, and duration of surgery.
Results
There was no statistically significant difference in the intraoperative hemodynamics between the two groups. The bispectral (BIS) value, end-tidal isoflurane concentration, and fentanyl requirement were comparable in the two groups. There was no significant difference in the blood sugar levels between the two groups.
Conclusion
In this study, we could not demonstrate the beneficial effects of intraoperative music as a nonpharmacological intervention under general anesthesia on stress response and anesthetic requirement.

Keywords: laparoscopic surgery, music therapy, stress response


How to cite this article:
Kalyani N P, Poonam G G, Shalini K T. Impact of intraoperative music therapy on the anesthetic requirement and stress response in laparoscopic surgeries under general anesthesia . Ain-Shams J Anaesthesiol 2015;8:580-4

How to cite this URL:
Kalyani N P, Poonam G G, Shalini K T. Impact of intraoperative music therapy on the anesthetic requirement and stress response in laparoscopic surgeries under general anesthesia . Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2019 Jun 20];8:580-4. Available from: http://www.asja.eg.net/text.asp?2015/8/4/580/172744


  Introduction Top


Music has been shown to modulate the mood, behavior and the psychology of the patient into a 'more positive frame of mind'. Music is known to affect the limbic system, which regulates deep emotions and many autonomic parameters. It evokes conditioned relaxation and aids in reducing stress levels. Listening to music coaxes the body to release its own endorphins [1] , thus altering the pain perception. Endogenous endorphin release has also been implicated as a mechanism in decreasing pain and analgesic requirements in some studies [2],[3] . The neural interconnections of the auditory pathway and the limbic system modulate emotional responses that are associated with the listening of music. Auditory interconnections with the hypothalamus, hippocampus, and the reticular activating system are presumed to attenuate the release of excitatory neurotransmitters, thus providing relaxation and the sedative effects of music [1] . A study conducted by Nilsson et al. [4] on patients undergoing hysterectomy under general anesthesia demonstrated that intraoperative music and music in combination with therapeutic suggestions may have beneficial effects on postoperative recovery.

We studied the impact of intraoperative music therapy on the anesthetic requirement and stress response in laparoscopic cholecystectomy performed under general anesthesia. Laparoscopic surgeries represent an anesthetic challenge as the creation of pneumoperitoneum is associated with hemodynamic changes such as tachycardia, increased blood pressure, increased airway pressures, and effectively increased anesthetic requirement. Laparoscopic cholecystectomy was selected as it predictably leads to increased hemodynamic stress responses [5],[6] . Music therapy is a simple, inexpensive, and noninvasive intervention that can be applied advantageously during intraoperative and postoperative care. In clinical practice, a combination of pharmacological and nonpharmacological treatments is desirable to achieve additive or synergistic effects and to reduce the side effects associated with polypharmacy. Music therapy is an example of a nonpharmacological activity that can be administered to the surgical patient.


  Materials and methods Top


After approval of the hospital ethical committee and written informed consent from every patient, 60 ASA I patients, aged 18-50 years and scheduled for laparoscopic cholecystectomy under general anesthesia, were enrolled for this prospective, randomized and double-blinded study, which was performed at Srimati Kashibai Navale Medical College and General Hospital (Pune, India), from July 2013 to December 2014. Patients with hearing impairment, hormonal dysfunction, steroid use, and psychiatric disorder were excluded from the study.

Patients were randomly assigned to two groups of 30 patients each, using a computer-generated random list (Epi info software, Centre for Disease Control and Prevention (CDC) in Atlanta, Georgia, USA, version 7.1.14): the music group (M) and the no-music group (NM). On arrival to the OT, standard monitors such as ECG, NIBP, pulse oximetry, and BIS monitor were attached, and baseline values were noted. Baseline capillary blood sugar level (BSL) was recorded using a glucometer. All patients were given occlusive headsets connected to a CD player. The patients in group M were made to listen to classical, instrumental music, which was played 5 min after intubation until wound closure, whereas patients in group NM were not played any music. The CD player was covered for observer blinding. Premedication was carried out with intravenous injection of midazolam 0.03 mg/kg and fentanyl 1.5 mcg/kg. All patients received glycopyrrolate 4 mcg/kg and ondansetron 4 mg injection intravenously. General anesthesia was induced with propofol injection, in induction dose (until the loss of eyelash reflex), and vecuronium 0.1 mg/kg to facilitate intubation with an appropriate size cuffed entotracheal tube.

Anesthesia was maintained with 50% oxygen in air and isoflurane adjusted (0.3-1.5% end-tidal concentration) to maintain BIS value between 50 and 60. Fentanyl boluses of 1 mcg/kg were given as and when required to maintain the BIS value. Neuromuscular blockade was monitored with peripheral nerve stimulator and vecuronium doses were given accordingly. Response to pneumoperitoneum (changes in heart rate, mean arterial pressure, BSL) was documented. Requirement of additional doses of fentanyl and isoflurane end-tidal concentration was noted. The aim was to maintain BIS value between 50 and 60. The hemodynamic parameters, end-tidal isoflurane concentration, Fentanyl doses, BIS value, and BSL values were recorded at following times: T1, immediately after intubation; T2, 5 min after creating pneumoperitoneum; T3, at skin closure; and (T4) 30 min after arrival to the recovery room. Mean arterial pressure and heart rate were also recorded. At the end of wound closure, the CD player was stopped and the headset was removed. Residual neuromuscular blockade was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. The patient was extubated after return of consciousness and protective airway reflexes. For postoperative analgesia, aqueous diclofenac sodium was added in 100 ml normal saline and given over 30 min. At 24 h after the surgery, patients were interviewed to determine any recall of intraoperative use of music.

The sample size was estimated from the data of previous studies, using an a level of 0.05 and a b level of 0.90 to establish a desired power of 0.80. Statistical analysis was performed using Primer of Biostatistics Statistical Software (McGraw Hill Global Education Holdings, LLC). The parameters were presented as mean ± SD and the unpaired t-test was used for comparing the demographic and clinical data. For the comparisons, P value of 0.05 or less was considered as statistically significant. The sample size was calculated using the a priori power analysis, setting a to 0.05 and power to 0.8.


  Results Top


There was no statistically significant difference between the two groups with respect to demographic profile, baseline hemodynamic variables, and duration of surgery [Table 1].
Table 1 Distribution of participants on the basis of demographic profile and baseline vital signs

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There was no statistically significant difference in the intraoperative hemodynamics between the two groups. The BIS value, end-tidal isoflurane concentration, and fentanyl requirement were comparable in the two groups. There was no significant difference in the BSLs between the two groups [Table 2].
Table 2 Hemodynamic changes and anesthetic requirement

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When questioned 24 h after the surgery, no patient recalled of hearing music during the surgery.


  Discussion Top


In our study, intraoperative music as a non-pharmacological intervention had no significant effect on intraoperative anesthetic requirements and stress response in laparoscopic cholecystectomy performed under general anesthesia. Music interventions are being increasingly used before, during, and after surgical procedures to address a number of patient outcomes. Various studies have demonstrated the beneficial effects of music on stress in general and on well-being and the need for sedation during regional anesthesia [7],[8],[9],[10],[11] . Studies on effect of music interventions under general anesthesia show inconsistent results. A few studies have demonstrated a positive effect of intraoperative music, sounds, or therapeutic suggestions under general anesthesia on postoperative recovery and analgesic requirement [4],[12] , whereas other studies could not demonstrate the benefits of music interventions [13],[14],[15] . Several pharmacological interventions effectively reduced the stress response to surgery under general anesthesia [16],[17],[18],[19],[20] . There are very few studies on the effect of music on intraoperative anesthetic requirement and neurohumoral stress response under general anesthesia [15] . Surgical procedures are often unfamiliar and uncomfortable and even minor procedures can produce anxiety in patients. Research suggests that anxiety affects postoperative recovery, decreasing pain tolerance and impeding wound healing [21] , and that a reduction in preoperative anxiety can lead to decreased pain, vomiting, surgical complications, and recovery time [22] .

Bringman et al. [23] demonstrated a greater reduction in anxiety levels with music as compared with oral midazolam in elective day-care or short-stay surgeries. Ni et al. [24] concluded that day surgery patients may benefit significantly from musical intervention. Similarly, Wang et al. [25] found a 16% decrease in state anxiety in patients who listened to music for 30 min preoperatively.

A study by Nilsson et al. [4] suggests that patients exposed to intraoperative music in combination with therapeutic suggestions required less rescue analgesia on the day of surgery, mobilized sooner after the surgery, and were less fatigued at discharge. Sener et al. [26] speculated that intraoperative music reduced uncomfortable operating room noise, thereby reducing anxiety and increasing satisfaction. Lepage et al. [10] concluded that patients listening to music intraoperatively, under spinal anesthesia, required less midazolam to achieve the same level of relaxation as controls.

Research suggests that music used for anxiety or pain reduction should contain sustained smooth melodies, a general absence of strong rhythms, limited percussive movements, and no lyrics [27],[28] . In the present study we used classical instrumental music fulfilling the above characteristics.

Explicit memory of auditory stimuli such as music, words, stories, and poems disappears rapidly under general anesthesia [2

9]
. In our study, no patient had explicit recall of intraoperative music. Studies suggest that 0.4-0.45 minimum alveolar concentration of isoflurane abolishes both explicit and implicit memory [30] . However, even in the absence of postoperative recall, processing of auditory stimuli still occurs under general anesthesia [31] . In our study, we maintained BIS value between 50 and 60 to increase the possibility of normal processing of auditory stimuli. Brain stem auditory-evoked response wave forms are resistant to both intravenous and inhaled anesthetic drugs. Large doses of fentanyl and isoflurane do not increase the latency of the response [32],[33] . This justifies the use of fentanyl boluses in our study to maintain BIS value between 50 and 60.

There are some limitations of our study. We could not measure the plasma levels of cortisol or ACTH, the direct indicators of neurohumoral stress, due to lack of facility at the institutional laboratory. We used blood glucose levels as an indirect indicator of stress response. Hyperglycemia and glucose intolerance are common manifestations of perioperative stress. Blood glucose levels increase after surgery begins. Cortisol and catecholamines facilitate glucose production as a result of increased hepatic glycogenolysis and gluconeogenesis. Blood glucose concentrations are related to the intensity of the surgical injury; the changes follow closely the increases in catecholamines [19],[34],[35] . Another limitation of our study was that we did not apply anxiety tests to the patients. People who differ in trait anxiety are known to exhibit differential autonomic responsiveness to a stressful situation [36] . Studies indicate that expert-chosen, research-based musical selections are more effective compared with patient-selected music [27],[28] . Although we used classical instrumental music meeting the research-based criteria, we did not include a music therapist in our study for the selection of music.

In conclusion, in this prospective, randomized, double-blind study, we could not demonstrate the beneficial effects of intraoperative music as a nonpharmacological intervention under general anesthesia on stress response and anesthetic requirement. Considering the aforementioned limitations, further studies are needed to confirm the results obtained in our study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2]


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