1. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com1 Music as an Adjunct to Anesthesia: A Review of the Research Cleveland Clinic Florida Grand Rounds Presentation Alice H. Cash, Ph.D., LCSW April 1, 2011

2. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com2 Cleveland Clinic Cleveland Clinic has been a pioneer in the use of music during surgery

3. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com3 The Phenomenon of Rhythmic Entrainment Humans have been entraining to music since the beginning of time –Hand clapping –Dancing –Finger snapping –Swaying back and forth

4. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com4 Early publications suggesting benefits of music in surgery (1998) “Use of intraoperative music in awake patients decreases patient- controlled sedative and analgesic requirements.” “Thus, the decrease in sedative and analgesic requirements could be caused by elimination of ambient operating room noise and not by the effects of music.”

5. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com5 The sedative and analgesic sparing effect of music. Yale University Hospital study (1998) Background: To determine whether music influences intraoperative sedative and analgesic requirements, two randomized controlled trials were performed. Methods: Phase 1 Phase 2 Results: In phase 1, patients in the music group required significantly less propofol for sedation than patients in the control group Similarly, in phase 2, patients who listened to music had a significant reduction in alfentanil requirements Duration of stay in the postanesthesia care unit and the rate of adverse events was similar in both groups (P = NS).

6. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com6 Music as an Adjunct to Anesthesia “The Efficacy of Music Therapy” Journal of Peri-anesthesia Nursing ( 2010 Aug; 25(4):226-32) Wakim JH, Smith S, Guinn C. University of Tennessee Being anesthetized is anxiety provoking can cause –An increase in blood pressure –An increase in heart rate –Other effects that can have a negative impact pre- operatively

7. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com7 Music’s Effect on the Body Rhythmic Entrainment is one of the most important concepts in the fields of music therapy and music medicine.

8. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com8 Music for Surgeons and Anesthesiologists Today music is often found in the operating room

9. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com9 Music for the Patient For decades, surgeons have used music in the operating room Rarely is the patient considered when the surgeon chooses his music. Ideally, the patient and the surgeon need their own unique types of music.

10. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com10 A Three-Part Playlist I recommend three distinct tempos of music for the surgical procedure. –Pre-Surgery –During Surgery –Post Surgery

11. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com11 A Three-Part Playlist Pre-Surgery –Music that is familiar to them and makes them feel safe and comforted is ideal. –Relaxing –Example: Edelweiss

12. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com12 A Three-Part Playlist Surgery: –Slow, steady purely instrumental music –Tempo of the healthy, resting heartbeat. –Perhaps “unknown” Ex: Baroque or classical movements. “Pachelbel’s Canon”

13. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com13 A Three-Part Playlist Recovery area –Little more upbeat –Possibly with positive, affirming lyrics Ex: “Morning has Broken” “When you Wish upon a Star” “The Rainbow Connection”

14. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com14 Reduction of Anxiety Before Studies have shown that listening to calm, steady music for 30-40 minutes before surgery, can greatly decrease the amount of anxiety medication needed. Some patients state that they are so relaxed by the music that they do not need any added anxiety medications prior to being sedated.

15. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com15 Reduction of Anesthesia During Procedure After listening to calm, soothing music for 30- 40 minutes prior to surgery, the patient arrives in the O.R. more calm and quiet.

16. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com16 Review of Recent Research Today, I will focus on research studies and articles between 2001- 2011. Although music has probably been used in one form or another for medical procedures over hundreds of years, we are only now understanding how to use it intentionally.

17. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com17 Review of Recent Research Relaxing music as pre-medication before surgery Acta Anaesthesiol Scand 2009 Jul:53 Dept of Surgery, Sodertalje Hospital Sodertalje, Sweden. Conclusion: Higher effectiveness and absence of apparent adverse effects makes pre-operative relaxing music a useful alternative to midazolam for pre- medication.

18. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com18 Review of Recent Research The effect of music on preoperative sedation and the bispectral index Anesthesia and Analgesia 2005 Jul; 101 Harran University, School of Medicine, Sanliurfa, Turkey Conclusions: Listening to music during midazolam pre-medication is associated with an increase in sedation level in the preoperative period as reflected by a lower BIS value.

19. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com19 Review of Recent Research The effect of music listening on older adults undergoing cardiovascular surgery. Nursing in Critical Care. 2006 Sep- Oct;11(5):224-31. Delray Medical Center, Delray Beach, FL Conclusions: Listening to music during and after cardiovascular surgery is an effective and safe intervention for older adults.

20. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com20 Review of Recent Research Music and ambient operating room noise in patients undergoing spinal anesthesia Yale University School of Medicine, New Haven, CT Anesthesia & Analgesia, 2005 May; 100 (5) Results: Intraoperative music decreases propofol requirements. We also found that Lebanese patients used less propofol as compared with American patients.

21. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com21 Review of Recent Research Clinical trial: music reduces anxiety levels in patients attending for endoscopy Alimentary Pharmacology Therapy 2009 Oct, Kent & Canterbury Hospital, Canterbury, UK.

22. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com22 Review of Recent Research Listening to music decreases need for sedative medication during colonoscopy Indian Journal of Gastroenterology 2006 Jan Feb;25(1):3-5, Medical College Hospital, Kozhikode 673 008, Kerala Conclusion: Listening to music during colonoscopy helps reduce the dose of sedative medications and decreases discomfort experienced

23. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com23 Review of Recent Research Music Therapy in Gastrointestinal Endoscopic Procedures. World Journal of Gastroenterology, 2007 Sep 7;13(33):4533 Background: To elucidate the role of music therapy in gastrointestinal endoscopic procedures following the conflicting outcomes reported in two recent studies Conclusions: The beneficial effects were shown on analgesia and sedation requirements and procedure duration times when used as an adjunct to pharmacotherapy.

24. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com24 Review of Recent Research Patients' perception of music versus ordinary sound in a post-anaesthesia care unit Intensive and Critical Care Nursing. 2009 Aug;25(4):208-13. Malmoe University Hospital, Sweden Conclusions: Promote the use of listening to music to establish a healing environment for patients in a post-anaesthesia care unit.

25. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com25 Review of Recent Research Music as a nursing intervention for postoperative pain: a systematic review University College in Dalarna, Falun, Sweden 2009 Dec;24(6):370-83.

26. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com26 Review of Recent Research The Effect of Music on postoperative pain and anxiety Pain Management Nursing 2010 Mar University of Central Florida, USA Background: Determine if listening to music or having a quiet rest period just before and just after the first ambulation on postoperative day 1 can reduce pain and/or anxiety or affect mean arterial pressure, heart rate, oxygen saturation, and respiratory rate Conclusions Nurses can offer music as an intervention to decrease pain and anxiety in this patient population with confidence,

27. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com27 Review of Recent Research Evidence That Music Listening Reduces Patients' Anxiety Biological Research for Nursing. Jan 28, 2011 Results: The music group demonstrated significant reductions in VAS scores, patients in the control group showed no changes; frequency-domain parameters of HRV can be indicators for monitoring the change

28. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com28 Review of Recent Research Effect of music therapy on postoperative analgesia and to determine the duration of its effect. Gülhane Military Medical Academy, Haydarpaşa Training Hospital, İstanbul, Turkey. Conclusion: Music therapy decreases postoperative pain in the first 24 hours and the analgesic consumption during the first four hours.

29. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com29 Review Recent Research The role of music during surgery and the effect on staff, users and patients Ahmadu Bello University Teaching hospital, Zaria. African Health Science 2010 Dec;10(4):386-9. Conclusion: music can prevent distraction, minimize annoyance, reduce stress and diminish the anxiety of patients, staff and users.

30. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com30 Review of Recent Research Monitored Anesthesia Care. Doctor’s Regional Medical Center, Corpus Christi, TX, USA. Conclusion: 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. 2010 American Society of PeriAnesthesia Nursing

31. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com31 Review of Recent Research Minimizing preoperative anxiety with music for day surgery patients Journal of Clinical Nursing. 2011 Feb 20. - a randomized clinical trial. Evaluate the effects of musical intervention on preoperative anxiety and vital signs in patients undergoing day surgery Relevance to clinical practice. Finding multimodal approaches to ease discomfort and anxiety from unfamiliar unit surroundings and perceived risks of morbidity

32. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com32 Conclusion and Recommendations Music is a powerful and effective adjunct to anesthesia and carries no known risks or downside. And yet music for the patient, is still rarely seen in the operating room. When the music is delivered through cordless headphones, the patient can have his optimal type of music and the surgeon and O.R. staff can have their preferred music.

33. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com33 Conclusion and Recommendations Current practices: –Music being used now is chosen by staff for their listening needs –Patients sometimes report not liking the music that is being played in OR. –Patients sometimes report hearing comments and conversations that are upsetting.

34. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com34 Conclusion and Recommendations Best practices –Music through headphones, offered to each surgical patient, starting 30-45 minutes before procedure –Same music be continued through-out the surgery –Either the same music or music with a slightly more upbeat tempo and positive affect into the recovery area until patient is awake and alert

35. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com35 Conclusion and Recommendations Safety and efficacy –Music is a safe and risk-free adjunct to traditional anesthesia and can assist in keeping the patient relaxed and comfortable while decreasing both anesthesia and analgesia

36. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com36 Conclusion and Recommendations Is There a Place for Music in Medical School? Music permeates the medical literature regarding disease therapy. However, there are only few articles concerning music as a tool for development of cultural competency and interpersonal relations. Medical Teacher. 2011;33(1):76-7. Boston University School of Medicine, MA 02118, USA.

37. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com37 Music as an Adjunct to Anesthesia: A Review of the Research Do you have any questions?

38. Dr. Alice H. Cash, Ph.D., LCSW chantdoc@gmail.com38 Music as an Adjunct to Anesthesia: A Review of the Research Thank You for your time today! (It’s something you don’t have a lot of….) Dr. Alice H. Cash chantdoc@gmail.com