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Address correspondence to: Fatma Dursun Ergezen, Faculty of Nursing, Department of Fundamentals of Nursing, Akdeniz University, Dumlupinar Boulevard, Antalya, 07070, Turkey
To evaluate the evidence for the effectiveness of music intervention on postoperative nausea and vomiting in the first 24 hours after surgery.
Design
A systematic review and meta-analysis of randomized controlled trials.
Methods
The study was conducted according to recommendations from Cochrane Handbook. The studies were selected based on PICOS inclusion and exclusion criteria. The revised Cochrane risk-of-bias tool for randomized trials was used for bias assessment and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used for reporting the study. Data was analyzed using the Comprehensive Meta-analysis version 3 software. A meta-analysis of randomized controlled trials was conducted using both fixed and random-effect models.
Findings
There were 576 patients in the seven studies who met the inclusion criteria. The number of participants ranged from 58 to 163. Music was implemented in postoperative, intraoperative, and perioperative periods. Meta-analyses revealed that music interventions significantly reduced postoperative vomiting (95% CI: 0.01 to 0.63, Z = 2.07, P < 0.05, Hedge's g = 0.32), and had no statistical significant effect on postoperative nausea (95% CI: −0.13 to 0.70, Z = 1.34, P > 0.05, Hedge's g = 0.28).
Conclusion
Music intervention is effective in decreasing postoperative vomiting. Music intervention can be applied by healthcare professionals and the patients. However, more studies are still necessary to estimate the effects of postoperative nausea and vomiting and to increase the amount of available evidence.
Postoperative nausea and vomiting (PONV) refers to the occurrence of nausea and/or vomiting or retching in the postanesthesia care unit (PACU) or during the first 24 to 48 hours after surgery.
PONV is the second most common complaint, with an estimated incidence rate in the general surgical population ranging from 30% to 40%, but can reach as high as 70% to 80% among high-risk patients.
A meta-analysis that included 23 studies reported that PONV prevalence was higher during the first 24 hours after surgery, and the overall prevalence of PONV among 21,276 patients was 27.7%.
There are multiple causative factors associated with PONV such as gender, age, history of motion sickness, type of surgery, duration of surgery, anesthesia technique, postoperative opioids, non-smoking, adverse drug reactions, anxiety, motion, pain, hypoxemia, and hypotension.
If PONV is managed ineffectively, adverse events such as aspiration pneumonia, dehydration, electrolyte imbalance, pain, subcutaneous emphysema, pneumothorax, esophageal rupture, and wound dehiscence may occur.
Therefore, the physiological mechanism should be understood to best adopt optimal precautions against adverse outcomes.
The physiological mechanism of PONV is complex and involves five primary afferent pathways as follows: the chemoreceptor trigger zone, the vagal mucosal pathway in the gastrointestinal system, neuronal pathways from the vestibular system, reflex afferent pathways from the cerebral cortex, and midbrain afferents.
The chemoreceptor trigger zone is responsible for receiving input from vagal afferents. Here, the chemoreceptor trigger zone is stimulated by emetogenic toxins, metabolites, and drugs circulating in the blood; also, it communicates with the nucleus tractus solitaries via dopamine-2 receptors. Meanwhile, vagal afferents are stimulated by paracrine factors from enteroendocrine cells that detect circulating drugs or local toxins in the gastrointestinal tract. The nucleus tractus solitaries is located in the area postrema and receives vagal afferent inputs from the vestibular and limbic systems.
Considering all these pathways and receptors, it is clear that PONV should be treated comprehensively and with multiple approaches.
International guidelines and systematic reviews indicate that there is currently no evidence of the best therapy or pharmacological agent for the management of PONV.
The guidelines based on the Enhanced Recovery after Surgery Society pathway suggest variable approaches should be adopted according to the type of surgery. However, since every surgical intervention has the potential to cause nausea and vomiting, the following widely applicable recommendations have been made: patients should be screened to assess their risk status, baseline risks should be reduced, combination antiemetics should be administered as prophylaxis, and multimodal approaches should be adopted.
Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: enhanced recovery after surgery (ERAS®) society recommendations.
Nurses are in a vital position to identify risk factors, consider possible prophylactic and additional interventions, assess the patient's status, and administer appropriate rescue antiemetic drugs.
Considering the negative effects of PONV on patients’ recovery and the recommendations of existing guidelines, it is important to accurately determine patient status and manage it effectively.
Pharmacological and non-pharmacological approaches are used in the management of PONV. Music is one of the most salient and frequently investigated approaches that has existed among these interventions in recent years.
The American Music Therapy Association defines music in this context as a purposeful and therapeutic modality introduced by health care professionals, the patient, or a music therapist.
Studies have reported that music intervention elevates brain waves; improves sleep quality; and enhances the immune response, well-being, and mood. Also, music stimulates relaxation and reduces pain, anxiety, muscle tension, depression, and stress levels.
Although the positive effects of music on health are known, there is no systematic review and meta-analysis on the effect of music intervention on PONV. It is very important to evaluate, develop and test the evidence stated in RCTs that music intervention reduces PONV. There is a need for an examination of the music interventions to reduce PONV, frequency of use, and the effect size of the intervention. These results may be important in clinical decision-making. This systematic review and meta-analysis may contribute to informing health care providers and researchers about the management of PONV in patients post-surgery.
Methods
Aim
This systematic review and meta-analysis sought to evaluate the evidence for the effectiveness of music intervention on PONV in adult patients in the first 24 hours after surgery in randomized controlled trials. The research questions were as follows:
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What type(s) of music were used in the included studies?
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For which surgical period was the music implemented?
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Did music intervention have an effect on postoperative nausea?
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Did music intervention have an effect on postoperative vomiting?
Design
The systematic review and meta-analysis were conducted according to recommendations from the Cochrane Handbook version 6.1,
Higgins J, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions version 6.1 (updated September 2020)2020. Available at: www.training.cochrane.org/handbook
Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. 2009;6:e1000097.
The search terms included appropriate Medical Subject Heading (MeSH) terms and the other relevant keywords selected according to PICOS elements (Appendix A). These elements involve the patient population (P), intervention (I), the comparison group (C), the outcome (O), and the study design (S).
Higgins J, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions version 6.1 (updated September 2020)2020. Available at: www.training.cochrane.org/handbook
The studies were selected according to the inclusion and exclusion criteria of PICOS elements. The inclusion criteria were as follows:
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Population: Participants should be age ≥ 18 and received postoperative care
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Intervention: comprised of all types of music intervention
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Comparison: the control group received routine care (regular and planned care) or no music intervention
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Outcomes: studies in which the PONV was measured in first 24 hours after surgery by self-report questionnaire and reported
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Study design: randomized controlled trials published in English
The exclusion criteria were as follows: studies that compared music intervention without a control group; studies in which the PONV was not measured by self-report questionnaire and not reported; studies with non-randomized controlled trials, cross-sectional studies, retrospective, prospective or concurrent cohort studies, abstracts, reviews, commentaries, conference proceedings, case reports, editorials and studies published in languages other than English.
The databases included CINAHL COMPLETE (Cumulative Index to Nursing and Allied Health Literature), Cochrane Central Register of Controlled Trials, Web of Science, PubMed, ScienceDirect, Ovid, ProQuest, and Networked Digital Library. Databases were searched for studies published in English without year limitation in November 2020 (Appendix B). Under the inclusion and exclusion criteria, firstly, an evaluation was performed of the title and summary; then, the full text was reviewed. Eligible studies were finally selected according to the PICOS inclusion and exclusion criteria (Table 1).
Table 1Inclusion and Exclusion Criteria
Elements
The inclusion criteria
The exclusion criteria
Population
Participants should be age ≥ 18 and take postoperative care
Participants who did not undergo surgery and are age ≤ 18
Intervention
Music interventions
The pharmacological and other complementary approaches (acupuncture, acupressure, etc.)
Comparator
Routine care or no music intervention
Studies were compared based on either pharmacological or other complementary approaches
Outcomes
Postoperative nausea or postoperative vomiting was evaluated in the first 24 hours after surgery
Postoperative nausea and vomiting not measured or data results not specified
Study design
Randomized controlled trials or mixed methods studies including randomized controlled trials
The search strategy identified 1,284 studies from the selected electronic databases, with 982 unique studies identified after all duplicates were removed. After the titles and abstracts were reviewed, 968 of the studies were removed because they did not meet the inclusion criteria. The remaining 14 full-text articles were screened for eligibility and seven studies were excluded for the following reasons: no statistical analysis (n = 2), did not meet the inclusion criteria (n = 4), and reported PONV as a single statistical result (n = 1). Finally, seven articles were included in this systematic review and meta-analysis based on eligibility per the inclusion criteria. The results of the screening and selection process are reported in the flowcharts
Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. 2009;6:e1000097.
The studies were independently evaluated by two researchers using the second version of a risk-of-bias tool for randomized trials (RoB2). Inconsistencies were rechecked and discussed by three researchers until consensus was reached. This analysis considered the following bias domains
Higgins J, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions version 6.1 (updated September 2020)2020. Available at: www.training.cochrane.org/handbook
Bias due to deviations from the intended interventions
-
Bias due to missing outcomes data
-
Bias in measurement of the outcomes
-
Bias in the selection of the reported results
-
Overall bias
A proposed judgment about the risk of bias was generated by an algorithm created by Cochrane in Excel. The risk of bias of included studies was evaluated in three levels: low risk, some concern, and high risk (Figure 2).
Figure 2(A) Risk of bias summary (B) Risk of bias graph. This figure is available in color online at www.jopan.org.
Two authors performed the data extraction and disputes were resolved with input from the third author. Firstly, duplicated studies were removed using the software Endnote X8. The studies were evaluated in terms of their titles and abstracts, and irrelevant studies were removed. Then, the studies were assessed in terms of inclusion and exclusion criteria. The two authors independently selected the studies, and the assessment differences were discussed until consensus was reached among the authors.
A standardized form was used to obtain relevant data from both intervention and control groups, which included the following: (1) author, year, country; (2) participants; (3) type of music and/or genre; (4) period in which the music was implemented; (5) control group; (6) outcome measures; and (7) results. In all studies, the control group was treated with standard care or a different music intervention. Microsoft Office Excel was used to prepare the data set of the meta-analysis.
Data Synthesis
The data were analyzed using the Comprehensive Meta-analysis (CMA) version 3 software. If a study measured results at different time points, the most recent intervention results were included in the meta-analysis. There are three Hedge's versions for effect sizes: Hedge's g, Hedge's gAV, and Hedge's gRM. The Hedge's g is recommended use for independent groups and corrects for bias in small samples.
The meta-analysis results were presented in the form of Hedge's g with p-values and 95% confidence intervals and summarized using forest plots. To estimate the effect size with 95% confidence intervals, Hedge's g was used, employing posttest mean and standard deviation values. Hedge's g was used to estimate of effect size as follows: small (0.2–0.5), medium (0.5–0.8), and large (> 0.8).
Statistical heterogeneity between studies was explored using the I2 coefficient, which describes the rates of the variability in effect estimates that is due to heterogeneity rather than sampling error.
The I2 statistics were interpreted as follows: 0% to 40% suggested the result was not important, 30% to 60% suggested moderate heterogeneity, 50% to 90% suggested substantial heterogeneity, and 75% to 100% suggested considerable heterogeneity.
Deeks JJ, Higgins JP, Altman DG. Analyzing data and undertaking meta-analyses. In: Deeks JJ, Higgins JP, Altman DG, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). 2020. Available at: www.training.cochrane.org/handbook
Cochrane's Q statistic was used to detect the presence of statistically significant variance. When the P value of the Q-value from the chi-squared test was less than 0.05 or I2 was greater than 30%, we used the random-effects model. Both random- and fixed-effect models were used in the present meta-analysis. The funnel plots and Egger's regression test were used for assessing publication bias.
Statistical significance was considered according to a two-tailed p-value of less than 0.05.
Results
Characteristics of the Included Studies
The characteristics of the included studies are presented in Table 2. A total of 576 participants across the seven studies were included in the systematic review and meta-analysis, ranging from 58 to 168 per study. Two studies were conducted in Sweden, while one each was conducted in Turkey, the United States, India, Denmark, and Iran. The included studies were published between 2001 and 2019.
In the included studies, the type, genre, duration, frequency, and the music implementation period were described. Six studies used passive music and one study used both active and passive music. Turkish art, folk, classic, soft, relaxing and calming music were introduced.
Music was implemented in the postoperative period in three studies,
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
In two studies, music was implemented in the postoperative period for 20 to 30 minutes, and the frequency of the interventions ranged from six times a day to one session a day.
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
In another study, music was implemented between before surgery and at discharge from the day department, while there was no information about the duration of implementation.
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
In this systematic review and meta-analysis, occurrence rates of PONV were analyzed. The most frequently used scale to measure nausea was a numeric rating scale; other scales used to measure nausea included a visual analog scale and four-grade scale. Vomiting was assessed by asking the patient about such at a predetermined time point in two studies.
Effect of Music Intervention on Postoperative Nausea
The effectiveness of music intervention on postoperative nausea was compared between the intervention (n = 284) and control groups (n = 267) in six studies
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
; however, the overall effects of music intervention on postoperative nausea were not statistically significant (P = .18, Hedge's g = 0.28, 95% CI: -0.13 to 0.70, 551 patients). Cochran's Q (X2) test results confirmed considerable heterogeneity (Q = 28.46, df = 5, I2 = 82%, P = .000) (Figure 3) and a random-effects model was employed due to this fact. Publication bias was evaluated using funnel plots and Egger's regression test. The Y-axis shows the standard error value and the X-axis shows the funnel scatterplot (Figure 4). Egger's regression test yielded results of t = 1.31 and P = .25; as such, Egger's test did not detect significant publication bias.
Figure 3Effectiveness of music intervention on postoperative nausea. This figure is available in color online at www.jopan.org.
Subgroup analyses were performed between the intraoperative and postoperative implementation period in five studies. One study did not conduct subgroup analyses due to music implementation in the perioperative period.
The overall effect of music intervention introduced in the postoperative period on postoperative nausea was not statistically significant (P = .40, Hedge's g = 0.26, 95% CI: -0.35 to 0.88, 345 patients). Cochran's Q (X2) test results confirmed considerable heterogeneity (Q = 15.87, df = 2, I2 = 87%, P = .000). Egger's regression test yielded results of t = 1.06 and P = .47 and did not detect significant publication bias. Also, the overall effect of music intervention in the intraoperative period on postoperative nausea was not statistically significant (P = .41, Hedge's g = 0.47, 95% CI: -0.67 to 1.62, 131 patients) (Figure 3). Publication bias was not evaluated in this context due to the inclusion of only two studies in the analysis.
Effect of Music Intervention on Postoperative Vomiting
The effectiveness of music intervention on postoperative vomiting was compared between the intervention (n = 82) and control groups (n = 85) in two studies
and the overall effect of such was statistically significant, albeit small and positive (P = .038, Hedge's g = 0.32, 95% CI: 0.01 to 0.63, 167 patients). Cochran's Q (X2) test results did not confirm heterogeneity (Q = 1.031, df = 1, I2 = 3%, P = .310). Therefore, a fixed-effects model was used (Figure 5). Publication bias was not evaluated for postoperative vomiting because only two studies were included in the meta-analysis.
Figure 5Effectiveness of music intervention on postoperative vomiting. This figure is available in color online at www.jopan.org.
Results of the risk-of-bias assessment are summarized in Figure 2. The domain of the randomization process was evaluated under the following three headings: allocation sequence, allocation sequence concealed, and baseline differences between intervention and control groups. Six of the studies were considered to exhibit low-level bias.
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
Meanwhile, the domain of deviations from intended interventions was evaluated based on adherence to the intervention and six signaling questions covering the following areas: awareness of patients to assigned intervention; awareness of healthcare providers and patients to delivered intervention; balance with non-protocol interventions between groups, failures of implementing the intervention, non-adherence to the assigned intervention, and appropriate analysis regarding adhering to an intervention. All studies were judged as being at low risk of bias based on these criteria. Patients who listened to music in the intraoperative period were blinded together with caregivers and patients to the delivered intervention. There was no information about the participant blending process in one study,
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
Next, the domain of missing outcomes data was evaluated under the four signaling questions. All six studies were evaluated as low risk in the domain of missing outcomes. The domain of measurement of outcome was assessed depending on five signaling questions covering the appropriateness of the measurement method, differences in measurements between groups, awareness of outcomes assessors of the received intervention, and the influence of knowledge about the received intervention. All six studies were evaluated as being of low risk in this context. Finally, the domain of selection of reported results was evaluated using three questions covering compliance with reporting according to a pre-specified plan, multiple eligible outcome measurements, and multiple eligible analyses. Five studies were judged as being of low risk in this domain, while one study was of some concerns due to not reporting results according to the pre-specified analysis plan.
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
This systematic review and meta-analysis summarized data from seven randomized controlled trials including a total of 576 participants that were published between 2001 and 2019. In this study, we evaluated the evidence for the effect of music intervention on PONV in the first 24 hours after surgery. Although some meta-analyses exist assessing the effects of music intervention on different postoperative outcomes, insufficient evidence from randomized controlled trials on PONV is available. A meta-analysis that answers questions not raised by individual studies and resolves disputes arising from conflicting claims is advantageous in furthering knowledge in this area.
Higgins J, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions version 6.1 (updated September 2020)2020. Available at: www.training.cochrane.org/handbook
In this context, the present systematic review and meta-analysis offers significant details on the effectiveness of music intervention in PONV to health care providers and researchers alike.
As compared with routine care, music intervention showed a small yet significant effect on postoperative vomiting, but no significant effect on postoperative nausea. It is thought that different factors may have affected the results of this study. First, the heterogeneity of the included studies should be evaluated; ultimately, this meta-analysis displayed substantial heterogeneity. In a meta-analysis, there can be various causes of heterogeneity. Clinical variation leads to heterogeneity and the true intervention effect is different in different studies. Methodological factors (blinding, concealment of allocation sequence, the measurement tool, etc.) may affect heterogeneity. Statistical heterogeneity arises from methodological diversity or differences in outcome assessments. Clinical and methodological diversity always occurs in a meta-analysis, making statistical heterogeneity inevitable.
Deeks JJ, Higgins JP, Altman DG. Analyzing data and undertaking meta-analyses. In: Deeks JJ, Higgins JP, Altman DG, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). 2020. Available at: www.training.cochrane.org/handbook
In this study, the high degree of heterogeneity reported may be related to: differences in the type of surgery performed, period of the music implemented, instruments used for assessment, study population size (58–168), number of intervention sessions (1–6 sessions), and timing of the evaluation of the effectiveness of the intervention. In this context, more research should be conducted in similar conditions, which would reduce methodological and statistical heterogeneity.
Other factors influencing the results of this study include variables affecting PONV. Several factors can affect the mechanism of PONV, including those that are patient-related (eg, sex, smoking, and motion sickness), intraoperative (surgical or anesthesia-related), or postoperative (eg, pain, ambulation, and analgesic opioids).
It has been reported that factors such as the type of anesthesia and surgery, and the duration of the surgery have a significant effect, increasing the prevalence of PONV. A meta-regression study where the experiences of 10,317 participants were analyzed found that the risk ratio for the overall effect of nitrous oxide on PONV was 1.21, increasing by 20% per hour after 45 minutes.
When considering the type of surgery, during a meta-analysis, it was reported that cholecystectomy, gynecological, and laparoscopic surgeries are correlated with a higher incidence of PONV.
However, these factors cannot be controlled by nursing interventions. For this reason, it is inevitable that some patients will experience PONV and it seems unlikely that music intervention would hinder or completely stop the mechanism behind the effects of these factors.
All surgical interventions cause pain, anxiety, and stress.
These factors are also extremely common among individuals who experience PONV. It has been reported that anxiety-induced nausea and vomiting appear to originate in the cerebral cortex, which communicates directly with the nucleus tractus solitaries via several types of neuroreceptors.
Also, in a longitudinal study conducted with 248 patients, those in the high-pain group reported a greater degree of nausea within the first five days after surgery.
Several studies show that music is effective in reducing stress, pain, and anxiety. It was reported that music intervention decreases the beta-endorphin levels, modulates activity in limbic regions (ie, amygdala and hippocampus), and affects the parasympathetic neural system. Also, with the activation of all these systems, enkephalin, endorphin, dopamine, and serotonin levels increase and cortisol levels decrease. As a result, the pain, stress, and anxiety levels of the patient are reduced and their mood improved.
Considering the effects of music intervention on pain, anxiety, and stress, it is thought that the modulation of these factors by music lessens nausea and vomiting. In a study conducted in this context, it was found that music intervention significantly reduced pain, anxiety, and nausea levels of the participants simultaneously.
In addition, in the two studies included in this meta-analysis, it was reported that the music intervention had a simultaneous positive effect on the pain, nausea, emotional status, and psychological well-being of patient.
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
This systematic review and meta-analysis revealed that different genres of music have been used in studies. Passive music was implemented in six studies, while both active and passive music were introduced in one study.
Art, folk, and classical music were used, depending on patients’ preference, while soft (eg, instrumental), relaxing, and calming music was also selected. There was no information about the music tempo across all studies included in this meta-analysis. Similarly, different genres of music were applied in other studies. The soothing, religious, cultural,
According to the guidelines for music-based interventions, researchers must consider some qualities of music when implementing, including form, tempo, rhythm, melody, harmony, voicing, and tonality.
In this context, more detailed information should be given considering these suggestions in future studies.
It has been suggested that the genre and tempo of music should be chosen based on surgery type. For instance, music with a slow physiological rhythm is more appropriate for cardiovascular surgery
An investigation into the use of recorded music as a surgical intervention: a systematic, critical review of methodologies used in recent adult controlled trials.
In one study included in this meta-analysis, art, folk, and classical music had a significantly reduced postoperative nausea (Hedge's g = 1.012, P = .000) and moderately decreased postoperative vomiting (Hedge's g = 0.532, P = .038). Another study showed that relaxing and calming music can significantly decrease postoperative vomiting (Hedge's g = 1.061, P = .000). In the context of these results, it can be said that choosing music that decreases physiological arousal may reduce PONV.
This systematic review and meta-analysis showed that music was implemented in different surgical procedural periods. Music was implemented in the postoperative period in three studies, in the intraoperative period in three studies, and perioperative period in one study. Music was implemented in the postoperative period,
The choice of the implementation period was based on the type of symptom. While studies that aimed to reduce anxiety have preferred the preoperative or perioperative period, studies that aimed to reduce pain have preferred the postoperative period. In this context, the period of music intervention should be carefully planned according to the onset and progress of the symptom.
In the studies implemented in the intraoperative period, music was listened to from the time of skin incision to wound closure.
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
The frequency and duration of music implemented in the postoperative period were also different; for example, music was listened to 20 minutes six times a day,
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
In the remaining two studies, the outcomes were evaluated on the evening of the surgery day with no evaluation performed immediately after the intervention.
Music intervention rapidly affects the human physiology and emotional state. If a patient has a long-lasting health problem, music may be implemented repeatedly and the outcome of such evaluated immediately after the intervention.
In this context, since nausea and vomiting continue for a long time in the postoperative period, it is thought that repetitive applications would be effective. A study that repeatedly applied music and evaluated the effectiveness of the intervention immediately thereafter reported that a large effect on PONV reduction was achieved.
For this reason, it is thought that studies are needed in which music is implemented repeatedly and the effectiveness on PONV is evaluated rapidly.
The small effect size revealed in this study does not mean that the clinical significance of the music intervention is unimportant. Effect size measures provide information about the magnitude of the effect. The effect may not always be clinically meaningful. Clinical significance supports that the effect of the intervention results in a meaningful change for individuals, clinical practice, or society.
Effect size and clinical importance are not always linear. Sometimes a large effect size may produce a clinically unimportant result, while a small effect size may produce a clinically significant effect.
It is recommended that the meaning of effect size should be interpreted within the clinical context of the problem as follow: (1) individuals return to normal functioning or experience a change in symptoms, (2) interventions improve quality of life, (3) changes in the outcome are important to society and/or (4) the outcome is acceptable as assessed by patient or expert ratings its impact on participants’ lives.
In this context, it is thought that considering the multidimensional aspect of PONV, a small effect size would have a clinically significance effect. Reduction in the patient's complaints, returning to normal functions, and reducing the need for treatment and monitoring are clinically significant effects. Therefore, even the small effect size will have a significant impact on clinical outcomes; however, more research is needed on this subject. It is believed that randomized controlled trials are necessary to test music interventions among different populations with the same surgical and anesthetic factors. Also, it is necessary to compare the effects of the music intervention based on the surgical period and music characteristics such as type, genre, duration, and tempo.
Strengths and Limitations
This study has three strengths. First, this was the first comprehensive meta-analysis to investigate the effects of music intervention on PONV in the first 24 hours after surgery. Second, this study was performed based on Cochrane principles. Finally, the investigators screened a large number of electronic databases to locate relevant studies.
However, this study also has two limitations. First, the number of studies included in the systematic review and meta-analysis was small. The number of studies may create a limitation in evaluating heterogeneity. While the Q test and P value are sensitive to the number of studies, the tau
Deeks JJ, Higgins JP, Altman DG. Analyzing data and undertaking meta-analyses. In: Deeks JJ, Higgins JP, Altman DG, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). 2020. Available at: www.training.cochrane.org/handbook
Clinical and methodological diversity always occur in a meta-analysis and statistical heterogeneity is inevitable. Thus, heterogeneity will always exist whether or not we happen to be able to detect it statistically.
Deeks JJ, Higgins JP, Altman DG. Analyzing data and undertaking meta-analyses. In: Deeks JJ, Higgins JP, Altman DG, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). 2020. Available at: www.training.cochrane.org/handbook
Therefore, it is recommended that more RCTs be performed using larger population sizes. Second, only literature in the English language was scanned and included in this study.
Conclusion
This systematic review and meta-analysis found that music has a small effect on postoperative vomiting and no effect on postoperative nausea. In all studies included in this systematic review and meta-analysis, the duration, frequency, and number of sessions of music intervention varied. More studies are still necessary to estimate the effects of PONV and to increase the amount of available evidence. A standard procedure should be developed to reduce PONV via music intervention. Also, this study can help patients, nurses, health care providers, and hospital managers in the management of PONV. The results constitute new evidence for inclusion in the literature and may guide future research efforts.
Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: enhanced recovery after surgery (ERAS®) society recommendations.
Higgins J, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions version 6.1 (updated September 2020)2020. Available at: www.training.cochrane.org/handbook
Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. 2009;6:e1000097.
Deeks JJ, Higgins JP, Altman DG. Analyzing data and undertaking meta-analyses. In: Deeks JJ, Higgins JP, Altman DG, eds. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). 2020. Available at: www.training.cochrane.org/handbook
Does intraoperative music therapy or positive therapeutic suggestions during general anaesthesia affect the postoperative outcome - a double blind randomised controlled trial.
An investigation into the use of recorded music as a surgical intervention: a systematic, critical review of methodologies used in recent adult controlled trials.
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