Music as an Aid for Postoperative Recovery in Adults a Systematic Review and Meta-analysis
Music intervention to save feet and pain in adults undergoing cardiac surgery: a systematic review and meta-analysis
Abstruse
Objectives Previous studies take reported beneficial effects of perioperative music on patients' anxiety and pain. We performed a systematic review and meta-analysis of randomised controlled trials investigating music interventions in cardiac surgery.
Methods Five electronic databases were systematically searched. Primary outcomes were patients' postoperative feet and pain. Secondary outcomes were hospital length of stay, opioid use, vital parameters and time on mechanical ventilation. PRISMA guidelines were followed and PROSPERO database registration was completed (CRD42020149733). A meta-analysis was performed using random effects models and pooled standardised mean differences (SMD) with 95% conviction intervals were calculated.
Results Twenty studies were included for qualitative assay (1169 patients) and sixteen (987 patients) for meta-analysis. The beginning postoperative music session was associated with significantly reduced postoperative feet (SMD = –0.50 (95% CI –0.67 to –0.32), p<0.01) and pain (SMD = –0.51 (95% CI –0.84 to –0.19), p<0.01). This is equal to a reduction of four.00 points (95% CI 2.56 to 5.36) and ane.05 points (95% CI 0.67 to 1.41) on the State-Trait Anxiety Inventory and Visual Analogue Scale (VAS)/Numeric Rating Scale (NRS), respectively, for anxiety, and one.26 points (95% CI 0.47 to 2.07) on the VAS/NRS for hurting. Multiple days of music intervention reduced anxiety until 8 days postoperatively (SMD = –0.39 (95% CI –0.64 to –0.15), p<0.01).
Conclusions Offering recorded music is associated with a significant reduction in postoperative anxiety and hurting in cardiac surgery. Dissimilar pharmacological interventions, music is without side effects so is promising in this population.
- cardiac surgical procedures
- coronary artery bypass
- center valve prosthesis implantation
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This is an open access article distributed in accordance with the Creative Eatables Attribution Non Commercial (CC Past-NC 4.0) license, which permits others to distribute, remix, adjust, build upon this piece of work not-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes fabricated indicated, and the use is not-commercial. See: http://creativecommons.org/licenses/by-nc/iv.0/.
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- cardiac surgical procedures
- coronary artery featherbed
- heart valve prosthesis implantation
Cardinal questions
What is already known about this subject field?
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Perioperative anxiety and pain are prevalent in patients undergoing cardiac surgery, despite the use of pharmacological interventions with well-known side effects.
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Music intervention has provided promising results in surgical patients.
What does this written report add?
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The results of this study provide some evidence for the beneficial effect of perioperative music intervention on postoperative anxiety and hurting in patients undergoing cardiac surgery.
How might this impact on clinical practise?
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Since music intervention has neither risks nor known side effects but may take a positive effect on the patients' health outcomes, healthcare professionals should consider providing perioperative music for patients undergoing cardiac surgery.
Introduction
Patients undergoing cardiac surgery oftentimes have perioperative anxiety and astringent postoperative hurting, despite the administration of benzodiazepines and opioids.ane–four Postoperative access to the intensive care unit of measurement (ICU) exposes them to stressors known to increase feet and pain, such as noise, sleeplessness, mechanical ventilation and immobility. These stressors may lead to longer hospitalisation and college utilize of benzodiazepines and opioids, with their inherent risk of side effects and adverse events.5–fourteen Research efforts take been directed towards approaches to relieve anxiety and pain. Apart from pharmacological therapies, not-pharmacological therapies have provided promising results.15
A music intervention is relatively inexpensive and an easily applicable non-pharmaceutical intervention which has no known side furnishings. Previous studies in mixed surgical populations accept establish statistically pregnant beneficial effects of perioperative recorded music on patients' anxiety, pain and neurohormonal stress response, with less consumption of intraoperative sedatives and postoperative opioids.15–xix Even so, these effects may not straight apply to patients undergoing highly invasive cardiac surgical procedures.
We performed a systematic review and meta-analysis to assess and quantify the effect of perioperative recorded music interventions on feet and pain in adult patients undergoing cardiac surgery. To the best of our cognition, this is the start written report of this kind.
Methods
This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines (see online supplementary data S1) and was registered in the PROSPERO database (https://www.crd.york.ac.uk/PROSPERO) equally record number CRD42020149733.20
Supplemental fabric
Search strategy
With the assist of a dedicated biomedical data specialist, we performed a search in the Embase, Medline Ovid, Web of Science, Cochrane CENTRAL and Google scholar databases for studies between i January 1992 and 25 October 2019. Keywords used in the literature search were "music" and "cardiac surgery". Online Supplementary data S2 gives a detailed description of the search terms and results per database. Reference lists of included studies were manually screened for additional studies that met the inclusion criteria.
Written report screening and option
2 authors (EK/RJB) independently screened all identified articles on title/abstract and full text co-ordinate to a standardised protocol.21 We have included studies with (P) developed patients undergoing cardiac surgery investigating the effect of (I) perioperative recorded music compared with a (C) control group on (O) feet and pain in (Southward) randomised controlled trials (RCTs). PICOS is a mnemonic used in testify based medicine and stands for, respectively; Patient, Intervention, Control, Outcomes, and Study22 type. Other inclusion criteria were assessment of surrogates of feet and hurting (use of opioids and vital parameters), full text bachelor in the English language and the use of perioperative recorded music in a hospital. Studies investigating the issue of music during a postoperative painful procedure (eg, chest tube removal, positioning of the patient) were excluded since such procedures reverberate just a fraction of postoperative anxiety and pain during hospitalisation. Music interventions were defined as the use of recorded music consisting of melody, harmony and rhythm, and offered in a hospital setting. Nature sounds were considered only when used in improver to music. If studies compared a music group to multiple other groups, the group without music that was most similar to the music group with respect to the intervention was chosen as the control group (eg, if groups were 'scheduled balance' and 'standard intendance', 'scheduled balance' was chosen as the control group if the music grouping also received a resting menstruum). Whatever disagreements between reviewers were resolved by the senior writer (JJ).
Information drove process and information items
2 of the authors (EK/RJB) independently extracted and checked the data from eligible studies co-ordinate to a pre-specified dataset. The following study characteristics were extracted: author proper noun, year of publication, sex, mean age, type of cardiac surgery, surgical method and numbers of patients in the intervention and control groups. The following intervention characteristics were extracted: blazon of music (genre, rhythm, beats per minute, how music was defined (eg, 'soothing music'), timing of the intervention (before, during or after surgery) and duration of the intervention (in minutes). Master outcomes were mean anxiety and pain scores assigned on the guidance of validated subjective assessment tools at baseline and subsequently the intervention. Secondary outcomes were infirmary length of stay (LOS, days), opioid use (morphine equivalents; mg), systolic blood pressure level (SBP, mmHg), diastolic blood pressure level (DBP, mmHg), hateful arterial pressure (MAP, mmHg), centre charge per unit (HR, beats/min), respiratory rate (RR, breaths/min), oxygen saturation (SpO2, %), and time on mechanical ventilation (min).
Quantitative analysis
Statistical analysis
Descriptive statistics are presented as means (SD), counts and percentages. For the main assay, a meta-analysis was performed for all main and secondary outcomes (except opioid use) using information for the first postoperative music session with immediate assessment of anxiety and/or pain. When multiple music sessions were practical, only data for the start postoperative session were used. The meta-analysis was performed using random furnishings models to calculate the overall treatment effect based on standardised mean differences (SMD), accounting for between-report heterogeneity. The between-written report variance was calculated with the restricted maximum likelihood method. The level of heterogeneity was assessed using the Iii statistic. Studies were included for quantitative analysis when hateful values and corresponding SDs of the primary and secondary outcomes were reported. Studies with significant differences in anxiety and/or pain scores at baseline were excluded from the quantitative analysis. To calculate the reduction for hurting and for anxiety based on the pooled SMD of the meta-analysis, a dorsum-transformation was practical to the anxiety and pain scores as described past the Cochrane Handbook for Systematic Reviews.23 For this back-transformation, the SDs of feet and hurting were estimated past pooling the SDs of the control groups for the dissimilar assessment tools separately.
In an boosted analysis, meta-analyses were performed for the primary outcomes using the data for the last session when multiple sessions were applied. For the main outcomes, subgroup meta-assay was performed on timing of the intervention (preoperatively, intraoperatively or postoperatively), how the music choice was assessed (eg, by the researcher or preference of the patient) and chance of bias due to the randomisation process (low risk was defined when both random sequence generation and allocation concealment were scored equally depression adventure, other studies were scored every bit high risk of bias). For utilize of opioids, a random furnishings meta-assay was performed to appraise the effect of the intervention on postoperative opioid use; where necessary, opioid use was accumulated over multiple postoperative days. If multiple types of opioids were administered, daily dosages were converted to morphine equivalents and summed to summate the total daily opioid use. The full dosage of opioids during the postoperative assessment period was determined by pooling the total daily dosages using formulas for pooled variance. Data were analysed using R version 3.6.3 and a two-sided p value <0.05 was considered statistically significant.
Qualitative analysis
Adventure of bias assessment
Selected articles were independently evaluated on risk of bias by the same two authors according to the Cochrane Gamble of Bias tool for RCTs.23 Incomplete data outcome due to drib-out of ≥10% was considered every bit high risk of bias. If the study protocol was not available, the run a risk for selective reporting was considered unclear. Funnel plots were made to assess publication bias. The GRADE (Grading of Recommendations, Cess, Evolution and Evaluations) criteria were used to assess the quality of the result of music on anxiety and pain, and to make clinical practice recommendations.23 24
Results
The literature search yielded 1537 results. After removal of duplicates, the titles and abstracts of 1018 articles were screened for relevance. Eventually, the full text of 36 of these articles and ii boosted articles were assessed for inclusion in the review. On the basis of the inclusion and exclusion criteria, 20 studies were included for the qualitative analysis (1169 patients) and 16 of these twenty studies (987 patients) for meta-analysis (see figure ane).25–44 The rate of understanding between the two reviewers was considered high (80%) on report choice and inclusion, risk of bias cess and data extraction.
Study characteristics
A detailed description of the study and music intervention characteristics is shown in online supplemental data S3. Cardiothoracic surgical procedures were more often than not coronary artery bypass graft and/or valve replacement (90%). None of the papers described the surgical method used. Eleven studies assessed anxiety (Country Trait Feet Inventory (STAI, 4/eleven), Visual Analogue Calibration (VAS, four/11) and Numeric Rating Scale (NRS, 1/11), Hospital Anxiety and Depression Calibration (HADS, ane/11), STAI and NRS (one/xi)) and ten assessed hurting (VAS (55.6%), NRS (33.3%), Visual Rating Calibration (VRS, 11.ane%)).
The blazon of music offered was commonly described every bit relaxing, calming, soft, allaying, light and absenteeism of strong rhythms and percussion (60%). Information technology was mostly offered through headphones (seventy%). The played music selection was either called by the patient from pre-selected music lists (40%), selected past the researcher (35%) or self-called by the patient (15%). Two studies used a combination of the above-described methods of music selection (ten%).31 43 Twelve studies (60%) provided multiple music sessions, either repeated on a twenty-four hours or days or one time daily over several day(southward). Patients in the control groups received a scheduled balance (viii studies, forty%), standard care (vi studies, xxx%), headphones/earphones without music (four studies, 20%), breathing exercises (1 study, ten%) or an intraoperative blank tape combined with postoperative standard care (one study, ten%).
Xiv studies solely provided postoperative music, of which seven were in the ICU,27 32 34 35 38 42 43 ii in the surgical ward,25 39 one in the ICU and ward26 and four did non specify.28 29 37 44 Five studies provided postoperative music in addition to preoperative and/or intraoperative music.31 33 36 40 41 I study provided both preoperative and intraoperative music.thirty In this study, reported result parameters during hospitalisation were assessed until postoperative day 8 and the duration of each music intervention was at least 20 min.
Risk of bias assessment
Figure 2 presents a detailed overview of the chance of bias assessment. Overall, the run a risk of bias was found to be moderate to high. A high take a chance of pick bias was considered nowadays in 3 studies (15%) due to open random resource allotment list,27 random sequence generation based on odd and even numbers33 and availability of the intervention,43 respectively. Five studies provided insufficient details regarding the random sequence generation (20%)34 39 40 42 44 and 11 studies (55%) regarding the allocation concealment.25 28 31 34 37–42 44 An overall high take a chance of performance bias was present, every bit blinding of patients to the intervention is just viable when the intervention is administered during full general amazement. Iii studies (15%) reported blinding of the personnel.38 40 41 Ii studies (x%) reported a high take chances of reporting bias, as issue parameters in the inquiry protocols differed from those in the published articles.33 35 Other risk of bias was considered high in two studies (10%); in one of these the patients in the control group were significantly older than the patients in the music group40 and the other lacked data on baseline characteristics such as age, sex and type of surgery.44 A summary of the risk of bias is shown in figure iii. The funnel plots investigating bias of studies on the effect of perioperative music on anxiety and hurting showed a near funnel-shaped plot (online supplemental data S4 and S5).
Event of music intervention on postoperative anxiety
Feet scores were pooled subsequently the beginning postoperative music session in nine of the 11 studies.25–27 thirty–33 36 44 The scores of two of these 11 studies could non be pooled considering SDs were lacking.28 29 The pooled assay resulted in a meaning effect of perioperatively offered music on postoperative feet (SMD = –0.l (95% CI –0.67 to –0.32), p<0.01). Anxiety was measured with the VAS (44%),26 27 32 36 STAI (33%),31 33 44 NRS (11%)25 or HADS (xi%).30 We performed a back-transformation on the xi-point VAS/NRS and the STAI scale, since these were virtually abundantly represented in the pooled information. This yielded a reduction of 1.05 (95% CI 0.67 to ane.41) points on the VAS/NRS for anxiety and 4.00 (95% CI 2.56 to five.36) on the STAI. The median elapsing of the intervention was xxx min (IQR twenty–105).25–27 32 33 36 44
Four studies offered postoperative music on multiple days.25 26 33 36 Pooling of the information collected after the last postoperative music session resulted in a reduction of postoperative feet (SMD = –0.39 (95% CI –0.64 to –0.15), p<0.01). The woods and funnel plots concerned are shown in online supplemental data S4.
Effect of music intervention on postoperative pain
Pain scores were pooled after the get-go postoperative music session in half-dozen of the 10 studies.26 32–34 36 39 The data from 4 of these 10 studies could non be pooled due to missing or unreliable means and SDs.28 29 35 42 The pooled assay resulted in a statistically meaning effect of perioperatively offered music on postoperative pain (SMD = –0.51 (95% CI –0.84 to –0.19), p<0.01). Hurting was measured with the VAS (66%),26 32 33 36 NRS (17%)34 or VRS (17%).39 Back-transformation yielded a reduction of 1.26 (95% CI 0.47 to 2.07) points on the VAS/NRS for hurting. The median duration of the intervention was 30 min (IQR 28–109).
Three studies offered postoperative music on multiple days.30 33 36 Pooling of the data nerveless after the last postoperative music session did non result in a meaning event on pain (SMD = –0.twoscore (95% CI –0.87 to –0.07), p<0.10). The wood and funnel plots concerned are shown in Supplementary information S5).
Course rating
Application of the Grade criteria led to the following considerations. The hazard of bias was moderate to high for both anxiety and hurting; the precision was considered depression, as effect sizes ranged from low to high within the 95% CIs of pooled estimates, influencing clinical controlling. Consistency was considered loftier for both anxiety and hurting, as all studies showed consequent results and all 95% CIs overlapped. Heterogeneity was statistically significant for pain (I2=56% (95% CI 0% to 82%), p=0.04) but not for feet (I2=0% (95% CI 0% to 63%), p=0.47); due to the wide CIs, the possibility of substantial heterogeneity cannot be ruled out for either result. Directness was considered loftier, as studies straight targeted the population of interest and reported outcomes critical for determination-making. At that place was no substantial evidence for publication bias, as scattering in the funnel plots for anxiety and pain was adequately symmetrical. Definite conclusions could not be drawn, however, because the number of studies assessing anxiety and hurting was small. In conclusion, the GRADE certainty rating is moderate.
Subgroup analysis
A combination of preoperative and postoperative music was administered by three studies assessing anxiety30 33 36 and by ii studies assessing pain.33 36 Pooled information analysis of these three and two studies did not result in a statistically meaning result on anxiety (SMD = –0.21 (95% CI –0.55 to 0.13), p<0.22) and pain (SMD = –0.57 (95% CI –ane.45 to 0.31), p=0.20). V studies assessing anxiety25–27 32 44 and iv studies assessing pain26 32 34 39 provided music solely postoperatively. Pooled data assay of these 5 and four studies resulted in a statistically significant effect for anxiety (SMD = –0.61 (95% CI –0.83 to –0.39), p<0.01) and pain (SMD = –0.46 (95% CI –0.82 to –0.11), p=0.01). Two studies assessing anxiety30 31 provided a combination of intraoperative and postoperative music. Pooled data assay showed no statistically meaning result on postoperative anxiety (SMD = –0.30 (95% CI –0.88 to 0.27), p=0.30). The information in question was not available for the effect on pain.
Subgroup assay of the relation between music selection and postoperative feet of four studies25 26 32 36 in which patients chose from pre-selected music lists resulted in a statistically meaning reduction (SMD = –0.51 (95% CI –0.77 to –0.25), p<0.01). The aforementioned type of assay of the ii studies33 44 in which patients provided their own music also resulted in a pregnant reduction in anxiety (SMD = –0.46 (95% CI –0.82 to –0.11), p<0.01). Pooled data analysis of 2 studies27 30 in which music was chosen by the researcher did not testify a statistically significant issue on anxiety (SMD = –0.41 (95% CI –i.26 to 0.41), p=0.32).
Pooled data analysis of five studies26 32 34 36 39 in which patients chose from provided playlists resulted in a statistically significant reduction in postoperative pain (SMD = –0.40 (95% CI –0.71 to −0.09), p=0.01). Nosotros could non puddle data on the event of patients' self-called or researcher-selected music on pain because in only one study could patients select their own music33 and in none of the studies did the researcher select the music. Forest plots are shown in online supplemental information S6.
The effect of music on anxiety is statistically significant for both depression risk (SMD = –0.44 (95% CI −0.83 to –0.05), p=0.03) and loftier adventure (SMD = –0.53 (95% CI –0.75 to –0.xxx), p<0.01) of bias studies based on the randomisation procedure. For pain the same analysis resulted in a non-significant effect for low-chance studies (SMD = –0.39 (95% CI –0.85 to 0.06), p=0.09) and a pregnant effect for high-risk studies (SMD = –0.69 (95% CI –one.01 to –0.36), p<0.01). Forest plots regarding this are shown in online supplemental data S6.
Upshot of music on other parameters
Every bit written in our PROSPERO protocol, we evaluated the consequence of perioperative music interventions on several other parameters. No statistically pregnant furnishings were found on perioperative opioid use, length of stay, fourth dimension on mechanical ventilation, systolic claret pressure, diastolic blood pressure level, hateful arterial pressure, heart rate, and respiratory charge per unit. Forest plots are shown in online supplemental data S7. The merely statistically significant finding was a minimal increase in oxygen saturation in the ICU (SMD=0.43 (95% CI 0.08 to 0.78), p=0.02).
Discussion
It is important to recognise and treat patients' perioperative anxiety, equally it has been associated with a higher postoperative pain intensity, lower quality of life, higher benzodiazepine and opioid consumption, and higher morbidity and mortality rates.45–49 Regarding the latter, Takagi et al concluded from a meta-assay that perioperative anxiety correlated with an almost twofold college late postoperative bloodshed compared with that in patients without perioperative anxiety.50 Also, the use of benzodiazepines for anxiety is controversial. While they are effective in reducing preoperative feet and promoting sedation, they have too been associated with a worse postoperative recovery and a college take a chance of delirium.51–55 Moreover, the utilize of benzodiazepines and opioids to reduce perioperative anxiety and pain in hospital may lead to chronic use and substance dependency.56 57 Introducing take chances-free music interventions for patients undergoing cardiac surgery is near likely toll effective as this may reduce patients' anxiety and pain, and consequently their benzodiazepine and opioid consumption.
This meta-analysis showed a pregnant beneficial effect of listening to music on postoperative feet and pain in patients undergoing cardiac surgery. These results are in line with the previous qualitative review of Grafton-Clarke et al.58 We performed the current written report in order to systematically review the literature with the help of an information specialist, in order to forestall missing of import manufactures on the field of study, and to quantify the crusade-effect relationship betwixt music and postoperative feet and hurting in patients undergoing cardiac surgery and to study the magnitude of the effect of music. Repeated music interventions postoperatively sustain the beneficial effect on feet until postoperative day eight. This effect is besides seen when studies were analysed separately based on the risk of bias due to the randomisation procedure, since this was the just chance of bias variable which could be divided into low and loftier take chances of bias. Our review establish that exposure to recorded music reduced postoperative anxiety past one.05 points on the VAS/NRS and iv.00 points on the STAI. A recent RCT comparing the effect of recorded music and that of midazolam on anxiety in patients undergoing a peripheral nerve block found no difference in this respect between the study arms.59 Interestingly, midazolam was associated with a reduction of 4.two points on the STAI, comparable to that which we found for music exposure. In the current report, for pain this reduction was ane.26 points on the VAS/NRS, which was a significant reduction.60 61 Also, the GRADE certainty was rated moderate in our study, which implies that the authors believe that these estimated clinical relevant furnishings are probably close to the true effect.
Postoperatively offered music significantly reduced postoperative hurting. This effect was non observed when we pooled data of studies providing preoperative music in combination with postoperative music. This was not expected, since preoperative anxiety is associated with postoperative pain. Yet, the low number of studies administering preoperative music resulted in loftier variability in the meta-analysis, and potentially led to an underestimation of the event. Therefore, definite conclusions cannot be drawn. Furthermore, this effect was likewise non observed when studies with low chance of bias and high risk of bias due to the randomisation procedure were analysed separately. Also, music significantly increased the mean oxygen saturation (SMD=0.43 (95% CI 0.08 to 0.78), p=0.02), but this increment was too low to be considered clinically relevant.
In our subgroup analyses on the touch on of music selection, the largest beneficial effect on anxiety was seen when patients selected music from preselected lists, followed by self-chosen music. Researcher-selected music had no statistically significant result on anxiety. Selecting music from a playlist also was associated with a beneficial consequence on hurting. Only one study assessing pain included cocky-chosen music, which showed a statistically meaning effect when the music was provided in the ICU on postoperative days 1–3.33 These findings are mostly in line with those of a meta-analysis of RCTs by Kühlmann et al, in which selection of music from a preselected listing had the largest beneficial event.fifteen Nonetheless, they as well found a statistically pregnant upshot of researcher-selected music on anxiety and pain. Discrepancies in the magnitude of the music effect between our meta-analysis and that of Kühlmann et al can be explained by the small number of studies included in our subgroup analyses, leading to a potential underestimation of the effect. Therefore, definite conclusions regarding music selection in patients undergoing cardiac surgery cannot be drawn. We did non find the beneficial effect of music on postoperative opioid use described past Fu et al.17 This can exist explained by the pocket-sized number of studies assessing opioid usage included in our meta-assay, and the utilise of standardised postoperative opioid regimens in these studies.
In more than half of the studies included in our review, music intervention was administered in the ICU. A meta-analysis by Richard-Lalonde et al investigating the effect of music in an developed mixed population admitted to the ICU also resulted in a significant positive effect of music on hurting.62 More chiefly, international guidelines for ICU care recommend offering music to reduce hurting and strongly recommend further enquiry of non-pharmacological interventions for the handling of anxiety and hurting, too to forestall delirium.63
As mentioned in the results, no effects were plant of music on more than objective parameters such every bit opioid use, length of stay, fourth dimension on mechanical ventilation, systolic blood pressure, diastolic claret pressure, hateful arterial pressure, heart rate, respiratory rate, and oxygen saturation. This is probably due to the fact that these parameters were mostly secondary outcome measures and thus no ability calculation was performed on these variables. As well, the sample sizes of the studies were relatively low, which results in difficulties drawing definite conclusions.
Strengths and limitations
A force of this review is the low heterogeneity between surgical procedures. Furthermore, the VAS and STAI for anxiety and the VAS for pain, which are reliable, validated and easy assessment tools, were the most ordinarily used tools in the included studies, facilitating the clinical interpretation. The nearly important limitation was the moderate to high risk of bias. Many studies did not provide sufficient details regarding random sequence generation and allotment darkening. Because our chief outcomes were patient-reported outcomes, the impossibility of blinding of the participants to the music intervention led to a high chance of detection bias. It is only feasible to blind patients when a music intervention is solely administered during general anaesthesia. This was not the case in any of the included studies. Therefore, farther research in the cardiac surgical population with music intervention solely being applied during general anaesthesia could have added value. The small numbers of studies included in our subgroup analyses prevented drawing definite conclusions regarding subgroups. Lastly, the timing, duration and type of music intervention varied profoundly betwixt studies, and meta-regression assay could non be performed due to the limited number of studies.
Future enquiry requirements
Future enquiry on music interventions in cardiac surgery should focus on sure methodological factors. In lodge to make definite conclusions, multicentre studies with larger sample sizes should be conducted, while nigh studies included in this meta-analysis have relatively low sample sizes. Furthermore, the gamble of option bias due to sequence generation and resource allotment concealment is easily solved by using a reliable randomisation method. The chance of performance and detection bias, even so, is more hard to avoid in music intervention studies since awake subjects and personnel are difficult to bullheaded, particularly in studies with subjective outcome measures. Lastly, there is nonetheless a lot of ambiguity in the current literature on the type of music, duration and frequency of the intervention. Therefore, it would be a cracking improver if studies with music interventions would report these factors in their studies in club to provide proper guidelines for implementation of music in standard medical care. Until these guidelines are implemented, nosotros recommend use of the published study protocol of the IMPECT trial (Interventions with Music in PECTus excavatum treatment) as a guide for future studies.64
Determination
This systematic review and meta-assay of RCTs indicates that perioperatively offered recorded music interventions were associated with a significant reduction in postoperative anxiety and pain in the cardiac surgical population. Music is easily applicable in the perioperative setting and has no known side effects. Therefore, implementation of perioperative recorded music intervention in the standard care of cardiac surgical patients should be considered.
Acknowledgments
The authors thank West Bramer, biomedical information specialist of the Medical Library at the Erasmus University Medical Center, for his assistance in the literature search and Ko Hagoort, Erasmus Medical Center, Rotterdam, for providing editorial advice.
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