Music Utilization in Sedation and Induction in Colonoscopy

Introduction Conscious sedation (CS) in the field of gastroenterology is commonly incorporated in order to alleviate pain and discomfort associated with interventional procedures. The use of CS to combat patient anxiety has been well documented [1]. Although CS is relatively safe, it is not immune to cardiopulmonary complications. Multiple studies have demonstrated a clear correlation between advancing age and procedure related complications [2-4]. It is also important to note that despite the lack of association between age and additional complications in a study conducted by Clarke et al, a third of their patients did not receive sedation/narcotic medications [5].

Obesity, which affects approximately two third of the U.S. population, has a myriad of health related risks and has been shown to contribute to the overall complications associated with endoscopic procedures [6]. Because those who are obese and overweight have higher than normal BMIs, BMI should not be ignored when assessing cardiopulmonary complications in patients undergoing endoscopic procedures. Moreover, a study by Qadeer et al. revealed that patients with high BMIs were more likely to experience hypoxic episodes [3].

A study by Sharma et al. (2007) looked at more than 300,000 patients who underwent endoscopic procedures while monitoring their risk factors for cardiopulmonary complications [4]. Older age, American Society of Anesthesia (ASA) grade value >2, inpatient procedures, and involvement of trainee with procedure were all shown to be associated with cardiopulmonary complications. In addition, another study by Bini et al.(2003) illustrated that the age of a patient, comorbid conditions, month of procedure (July and August), and midazolam dose were linked with increased negative outcomes [2]. The correlation between complication rate during procedures along with the year of the trainee conducting the procedure indirectly demonstrated the complications in the new academic year (July and August). Understanding that sedation during endoscopic procedures incurs significant risks particularly in patients who are underweight, obese or have numerous comorbidities can lead to steps aimed at better managing the aforementioned risks and reducing patient discomfort.

Music has been shown in many studies to decrease anxiety and improve patient satisfaction during and after procedures in cardiac, pulmonary and surgical procedures [7-16]. In regards to endoscopies, one hundred and eighty patients who were listening to music prior to endoscopic procedure had a significant reduction in stress compared to controls [17]. A similar type of study performed by Hayes et al. (year) revealed that music resulted in a statistically significant decrease in the State-Trait Anxiety Index (STAI) levels of patients undergoing an endoscopy [18] . In another study, music was played prior to and during procedure with no sedative/narcotic medications [19] . Patients with music experienced a decrease in blood pressure (BP) and RR compared to their counterparts who did not listen to music. A 3 point attitude scale showed that patients with music had less discomfort, illustrating that music has the potential to modulate physiological parameters. An instrumental composition from the album "Nada Himalaya" performed by S.G. Sachchidananda, was previously studied by Phanishree et al. (unpublished data), which demonstrated a decrease in the blood pressure and heart rate in patients. Furthermore, the patients were much more relaxed and calm compared to the beginning of the study. Other music genres have relaxation properties as well but we wanted to test one specific type of music to see proof of concept in colonoscopy before we introduce other genres.

Propofol is currently being used more frequently for the use of monitored anesthesia in surgical settings. Patients on propofol have a better recall that music was being played compared to general anesthesia, but they could not adequately recall the type of music [20]. Ambient room noise seems to be one of the main factors associated with increasing propofol requirements in an operation room (OR) which music seems to alleviate [21] . This has been further illustrated by the use of Bispectral index (BIS), which demonstrated increasing brain activity when OR decibels were over 50 [22]. With the initiation of music and propofol in the setting of spinal anesthesia, there was a significant decrease in propofol dose and cortisol levels intra-op demonstrating the stress relieving effect of music [23,24].