The Effects of Music, White Noise, and

Ambient Noise on Sedation and Anxiety

in Patients Under Spinal Anesthesia
During Surgery
Nazan Koylu Ilkkaya, MD, Faik Emre Ustun, MD, Elif Bengi Sener, MD,
Cengiz Kaya, MD, Yasemin Burcu Ustun, MD, Ersin Koksal, MD,
Ismail Serhat Kocamanoglu, MD, Fatih Ozkan, MD

Purpose: To compare effects of music, white noise, and ambient (back-

ground) noise on patient anxiety and sedation.
Design: Open, parallel, and randomized controlled trial.
Methods: Seventy-five patients aged 18 to 60 years who were scheduled for
surgical procedures under spinal anesthesia were randomly assigned to
ambient noise (Group O), white noise (Group B), or music groups
(Group M). We evaluated patients’ anxiety and sedation levels via the
Observer’s Assessment of Alertness/Sedation (OAA/S) scale and the
State-Trait Anxiety Inventory (STAI) questionnaire.
Finding: At 5 minutes before surgery, the STAI-State Anxiety Inventory
(SA) value was significantly lower in Group M than the other groups.
At 30-minute recovery, Group M showed significantly lower STAI-SA
values than the other groups. Patient satisfaction was highest in Group
M. OAA/S values were not significantly different between groups during
any period (P . .05).
Conclusions: We suggest that patient-selected music reduces perioperative
anxiety and contributes to patient satisfaction during the perioperative
period.
Keywords: music, white noise, ambient noise, patient anxiety.
Ó 2014 by American Society of PeriAnesthesia Nurses

THE PERIOPERATIVE PERIOD is not only a cause
of physical trauma but also an important source of
fear and anxiety among patients. One way to pre-
vent this is to sedate the patient.1 Patients oper-
ated under regional anesthesia are in particular
need of sedation during the perioperative period.
Awake patients in the operating room (OR) fear
that they will feel pain during the surgical and/or
regional anesthetic procedures, which contributes
to increased anxiety.2 The aim of the sedation is
to ensure the comfort, full cooperation, and
cardiovascular stability of patients who can main-
tain a patent airway. However, because of the
adverse effects (eg, respiratory depression,

Nazan Koylu Ilkkaya, MD, is Anesthesia Specialist from
Anesthesiology and Reanimation Department, Carsamba
State Hospital, Samsun, Turkey; Faik Emre Ustun, MD, Elif
Bengi Sener, MD, and Ismail Serhat Kocamanoglu, MD, are
Professors from Anesthesiology and Reanimation Depart-
ment, Faculty of Medicine, Ondokuz Mayis University, Sam-
sun, Turkey; Cengiz Kaya, MD, Yasemin Burcu Ustun, MD
and Ersin Koksal, MD, are Assistant Professors from Anesthe-
siology and Reanimation Department, Faculty of Medicine,
Ondokuz Mayis University, Samsun, Turkey; and Fatih
Ozkan, MD, is an Associate Professor, Department of Pain
Medicine, Faculty of Medicine, Ondokuz Mayis University,
Samsun, Turkey.
Conflict of interest: None.Funding: None to report.
Address correspondence to Cengiz Kaya, Anesthesiology
and Reanimation Department, Faculty of Medicine, Ondokuz
Mayis University, Samsun, Turkey; e-mail address: raufemre@
yahoo.com.
Ó 2014 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2014.05.008

418 Journal of PeriAnesthesia Nursing, Vol 29, No 5 (October), 2014: pp 418-426

THE EFFECTS OF MUSIC-NOISE ON SEDATION AND ANXIETY
nausea, vomiting), optimal patient satisfaction
is hard to achieve.3-5 Pharmacological and non-
pharmacological methods can be used to
decrease anxiety and the need for sedatives in
patients under regional anesthesia.1,3,6
In acoustics, noise is defined as any unpleasant
sound that interferes with audible voices. Shapiro
and Berland7 recommended that the noise level
in an OR should not exceed 55 to 86 dB. However,
in practice, the noise intensity in the OR is be-
tween 65 and 120 dB, which unfavorably affects
both patients and the operating team.8
Music is prevalent at every stage of an individual’s
life. In addition, its multifaceted impact on humans
has led to the use of music therapy. Therapeutic
use of music dates back to the sixth century BC.9
Music distracts one’s attention from negative stim-
uli toward pleasant feelings and may reduce pain,
anxiety, and stress.9-12 In addition, music enables
patients to flee into their own world that they
know very well and where they feel comfortable.
Music also focuses the patient’s awareness on the
music, which provides comfort.13
The frequency and signal of white noise generally
resembles the sound of waterfalls, ocean waves,
or wind sweeping through trees. White noise is
prepared by digitally mixing sounds of equal fre-
quencies in a laboratory. Then, all frequencies con-
tained in this sound are calibrated to form a white
noise that is pleasant to the senses.5 White noise en-
compasses all characteristics of sounds within the
range of human hearing. It has been used in the
treatment of tinnitus, insomnia, masking unwanted
sounds, and provision of relaxation.5,14
Patients experience anxiety about surgical inter-
vention, regional and local anesthesia, or other pro-
cedures. They also fear pain, discomfort, and
encounter many audiovisual stimuli when they
awaken in an unfamiliar environment. The use of
music therapy in addition to conventional methods,
or the masking of ambient noise with white noise
to alleviate fear and anxiety felt by the patients,
can decrease their discomfort, increase their
procedural comfort and tolerability, and can
favorably affect sedation and anxiety scores.15-17
A review of the literature found no previous ran-
domized controlled study of the effects of music,
419
white noise, and ambient noise on patient anxiety,
pain, sedation scores, satisfaction, and hemody-
namic parameters during the perioperative period
among patients undergoing regional anesthesia.
Therefore, the present study investigates the
effects of music, white noise, and ambient noise
on these parameters among patients operated
under spinal anesthesia who also received intrave-
nous (IV) infusion of midazolam.
Materials and Methods
This study was conducted in the Department of
Anesthesiology and Reanimation and was
approved by the Samsun 19 Mayis University
Ethics Committee of Clinical Investigations;
informed consent forms were obtained from pa-
tients. This trial is registered with the Australian
New Zealand Clinical Trials Registry, number
ACTRN12613000406707. This is a three-arm paral-
lel study (clinical trial in which three groups of par-
ticipants receive different interventions), and
allocation is not concealed.
The study cohort comprised 80 patients (Amer-
ican Society of Anesthesiologists [ASA] class I to
II) aged 18 to 60 years who underwent surgical,
urological, and orthopaedic operations. Those
with contraindications to regional anesthesia,
hearing impairment, history of psychiatric drug
use, hepatic, renal, or hormonal dysfunction, or
serious cardiopulmonary disorders were excluded
from the study. Patients were assigned by simple
randomization using a randomization table.18
Neither the patients nor the treating physicians
were blinded to treatment (open label). To avoid
interference with the results obtained, the partici-
pants were not premedicated. All participants
were questioned about their educational levels,
whether they liked to listen to music, where and
how often they listened to music, and their
musical training, if any.
The patients were randomly divided into three
groups that listened to ambient noise (Group O),
white noise (Group B), or self-selected music
(Group M).
Group O: Ambient noise in the OR was augmented
using an amplifier (Mini Amplifier, No: 9988; Ekin-
cioglu, Istanbul), and the patients used a headset
(SN-802; Snopy Segment Computer Foreign Trade
420
Co. Ltd., Istanbul) to listen to the ambient noise
both during and after the operation.
Group B: The patients selected one of three
compact discs containing white noise (babbling
brook, distant thunderstorm, restful rain; Pure
White Noise, Windsor, CO), to which they listened
during preoperative, postspinal, intraoperative,
and postoperative periods.
Group M: Numerous musical pieces (folk music) in
MP3 format were loaded onto a laptop computer.
Patients selected a playlist of their favorite songs
from the available list, which they listened to using
the same headset during preoperative, postspinal,
intraoperative, and postoperative periods.
When the patients entered the waiting room for
the first time, their states of anxiety and sedation
were evaluated using Visual Anxiety Scale (VAS;
0 5 very calm and 10 5 very anxious), State-
Trait Anxiety Inventory (STAI), and Observer’s
Assessment of Alertness/Sedation (OAA/S) scoring
systems. The OAA/S was graded as follows:
The patient (1) gives a response only when his or
her shoulders are prodded, (2) responds only after
his or her name is called loudly, (3) responds
slowly after his or her name is called with normal
tone, (4) responds normally when his or her
name is spoken with normal tone. The STAI con-
sists of two different parts, termed STAI-Trait Anx-
iety Inventory (STAI-TA) and STAI-State Anxiety
Inventory (STAI-SA). The first test determines base-
line anxiety level, and the second test indicates
anxiety level generated by environmental changes.
This test requires patients to complete a 40-item
questionnaire. Twenty items were prepared for
the STAI-TA scale and 20 items for the STAI-SA
scale. For each domain, the allocated scores range
between 20 and 80 points, representing the high-
est and lowest levels of anxiety, respectively. In
our study, STAI-TA test results were evaluated pre-
operatively. The STAI-SA was performed during the
preoperative period; before induction of prespinal
anesthesia, 5 minutes before surgical intervention,
and again 30 minutes into the recovery period.
In the preoperative waiting room, Group B pa-
tients listened to white noise, whereas Group M
listened to songs from their preprepared playlist
via a headset connected to a computerized system.
ILKKAYA ET AL
The sound level was maintained at the level the pa-
tient indicated as most comfortable.
When patients were brought to the regional anes-
thesia unit, their electrocardiogram, noninvasive
blood pressure, and saturation of peripheral oxy-
gen (SpO2) levels were monitored, and their pre-
operative baseline values were recorded. Oxygen
was delivered via a nasal cannula at a rate of 3 L/
minute. An IV access was opened using a
22-gauge intracath cannula, and 0.9% NaCl infu-
sion (8 to 10 mL/kg IV) was started. Before induc-
tion of spinal anesthesia, in addition to the
measurements of hemodynamic parameters, pa-
tients underwent VAS, STAI-SA, and OAA/S tests.
The patients stopped listening to musical pieces
or white noise during institution of spinal anes-
thesia. After maintenance of adequate hydration,
spinal anesthesia was achieved via administration
of 10 to 15 mg 0.5% hyperbaric bupivacaine. All
patients received 25 mcg/kg IV midazolam after in-
duction of spinal anesthesia. The hemodynamic
parameters, VAS, and OAA/S scores were evaluated
and recorded at 5-minute intervals before the
patients were taken into the OR. Five minutes
before lying on the operating table, the STAI-SA
scores were reevaluated for the third time.
In the OR, the patients underwent standard moni-
toring procedures. During the intraoperative
period, heart rate, diastolic/systolic blood pressure
(mean blood pressure), SpO2, respiratory rate,
VAS (0 to 10), and OAA/S (1 to 5) measurements
were performed at 5-minute intervals. All patients
received IV midazolam infusion at a dose of 0.5
mcg/kg/minute for the duration of the operation.
A drop of more than 20% in systolic blood pressure
relative to the baseline was indicative of a hypoten-
sive state and was treated with fluid replacement
and ephedrine (5 to 10 mg IV). Heart rates of
#45 bpm were considered as bradycardia, which
necessitated 0.5 mg IV atropine. A jaw thrust
maneuver was applied in patients with SpO2
values less than 90%; if that failed, midazolam
was discontinued.
At the end of surgery, IV infusion of midazolam was
stopped. The duration of anesthesia was deter-
mined and recorded as the time interval between
the induction of anesthesia to the end of the oper-
ation. The patients were transferred to the posta-
nesthesia care unit (PACU) and monitored for
THE EFFECTS OF MUSIC-NOISE ON SEDATION AND ANXIETY
30 minutes for hemodynamic parameters, level of
sedation, and occurrence of adverse effects. Vital
signs, OAA/S, and VAS scores were evaluated at
5-minute intervals in the PACU. Patients in Groups
M and B continued to listen to their favorite songs.
In all groups, STAI-SA scores were reevaluated
30 minutes later for the fourth time.
After evaluation of the effects of various types of
music on patient satisfaction (1: poor, 2: moderate,
3: good, and 4: excellent), the patients were trans-
ferred to their wards.
The data obtained were evaluated using SPSS (Win-
dows, version 21.0). Data were expressed as
percentages and mean 6 standard error. Data anal-
ysis used analysis of variance (ANOVA) for groups
with normal distribution and the Kruskal-Wallis
test for those with nonnormal distribution. For
the analysis of repeated measures, groups with
normal distribution used repeated-measures
ANOVA, whereas those with nonnormal distribu-
tion used the Friedman test. The chi-square test
was used to compare numerical data. A P value
of , .05 was regarded as statistically significant.
Assuming a statistical power of 80% and alpha of
5%, 25 patients were required in each group to
reach a level of significance. During the intraoper-
ative period, three patients in the white noise
group, and during the postoperative period two
patients in the music group refused to listen to mu-
sic, and were thus excluded from the study. The
analysis therefore included 25 cases from each
group (75 patients in total).
Results
No significant difference was found between the
three groups when the 75 patients were compared
for age, gender, body mass index, ASA class, dura-
Table 1. Demographic and Clinic Data of Participants (Mean ± Standard Error)
Demographic and Clinical Characteristics Group O (n 5 25) Group B (n 5 25) Group M (n 5 25)
Age (y)
Sex (female/male, n)
Body mass index
American Society of Anesthesiologists I to II (n)
Duration of anesthesia (min)
Duration of surgery (min)
421
tion of anesthesia and surgery, and types of surgical
intervention (Table 1). No significant difference
was found between the three groups when pa-
tients were compared for educational level, inter-
est in music, frequency and place of music
listening, and musical education (Figure 1; Table 2).
Hemodynamic parameters (heart rate and mean
arterial pressure) and respiratory rate did not differ
significantly between groups during the periods
assessed. OAA/S values were not statistically
different when measured at any time during the
preoperative, prespinal, postspinal, intraopera-
tive, and postoperative periods.
VAS values during the preoperative period were
higher than those during other times (P 5 .014).
There was no significant difference between VAS
values for the other periods. VAS values in Group
M were significantly lower than in Groups B and
O (P 5 .004 and .006, respectively), whereas VAS
values in Groups B and O were not significantly
different (P 5 .919) (Figure 2).
No significant difference was found between VAS
values estimated at intraoperative measurement
times. VAS values in Group M were significantly
lower than in Groups B and O (P 5 .005 and
.004, respectively); however, there was no signifi-
cant difference in VAS scores between Groups B
and O (P 5 .985) (Figure 3).
During the postoperative period, the VAS scores at
1 minute were significantly higher than those at 15
and 20 minutes (P 5 .024 and .015, respectively).
In intergroup comparisons, VAS values in Group O
were significantly higher than those in Groups M
and B (P 5 .001). No significant difference was
found between postoperative VAS scores for
Groups B and M (P 5 .985) (Figure 4).
P
31.76 6 10.9 32.2 6 10.9 32.6 6 10.4 .955
3/22 8/17 5/20 .221
26.1 26.4 25.4 .910
18/7 22/3 22/3 .226
47.8 6 15.6 53.0 6 14.9 57.9 6 22.2 .144
73.4 6 15.6 78.8 6 15.6 82.4 6 23.3 .234
422 ILKKAYA ET AL

In intergroup comparisons, in Group M, patient

satisfaction was significantly better when
compared with the other two groups. However,
Group B differed significantly from Group O (chi-
square 5 92.98, df 5 4, P 5 .000) (Table 4).

Discussion

Sounds and noises in our environment are compo-

Figure 1. Distribution of patients according to
educational level.
In intergroup comparisons, no significant differ-
ence was found between the three groups for pre-
operative STAI-TA, preoperative, and prespinal
STAI-SA scale scores. STAI-SA values estimated
5 minutes before surgery and at postoperative
30 minutes were significantly lower in Group M
compared with Group O. In intergroup compari-
sons, in Group O, preoperative STAI-SA value was
found to be significantly lower than that measured
5 minutes before surgery STAI-SA, whereas preop-
erative STAI-SA value was significantly higher than
that measured at 30 minutes of postoperative
STAI-SA (P 5 .041 and .032). Postoperative
STAI-SA value was significantly lower than its
prespinal estimate and that measured 5 minutes
before surgery (P 5 .008). Postoperative STAI-SA
was significantly lower than preoperative and pre-
spinal values and that measured 5 minutes before
surgery (P 5 .003) (Table 3).
nents of our daily lives and induce various psycho-
logical and emotional responses.19 Almost all
patients hospitalized for surgery are anxious, and
their level of anxiety increases as they wait to un-
dergo their scheduled procedures.20
Many studies reported prominent changes in hemo-
dynamic parameters and the release rates of
perioperative stress hormones in response to the
soothing effects of music.19,21 However, recent
investigations could not demonstrate variations
in hemodynamic parameters related to music
therapy. Zhang et al17 found no significant changes
in heart rate or in systolic and diastolic blood pres-
sure among two groups of patients (n 5 110) who
had or had not listened to music during abdominal
hysterectomy performed under combined spinal-
epidural anesthesia. Wang et al22 investigated the ef-
fect of music on preoperative anxiety in 93 patients
and found no marked differences in hemodynamic
parameters between two groups of patients who
had or had not listened to music. In our study, heart
rates and mean arterial pressure were within
normal limits and showed no significant differences

Table 2. Patients’ Personal Music Preferences According to Their Randomized Group Allocation
(Patients, n (%))
Personal Music Preferences Group O (n 5 25) Group B (n 5 25) Group M (n 5 25) P
Levels of interest in music
Strong 20 (80) 21 (84) 23 (92) .474
Moderate 5 (20) 4 (16) 2 (8)
Frequency of music listening
Several times a day 16 (64) 18 (72) 18 (72) .915
Once a day 5 (20) 4 (16) 5 (20)
Rarely 4 (16) 3 (12) 2 (8)
Location of music listening
Home 14 (56) 13 (52) 12 (48) .235
Car 9 (36) 4 (16) 7 (28)
Workplace 2 (8) 8 (32) 6 (24)
Musical education
No 24 (96) 24 (96) 20 (80) .159
Yes 1 (4) 1 (6.7) 5 (20)
THE EFFECTS OF MUSIC-NOISE ON SEDATION AND ANXIETY
Figure 2. Group VAS scores during the preopera-
tive period (mean 6 standard error). *P 5 .004 and
.006; significant difference when compared with
Groups B and O. t1, preoperative; t2, prespinal; t3,
postspinal 1 minute; t4, postspinal 5 minutes; t5,
postspinal 10 minutes; t6, postspinal 15 minutes;
t7, postspinal 20 minutes; t8, postspinal 25 minutes;
t9, postspinal 30 minutes. VAS, Visual Anxiety Scale.
between three groups of patients who listened to
either music, white noise, or ambient noise.
The findings of previous studies support the use of
OAA/S or bispectral index (BIS) in the assessment
of sedation.23-26 T€
ufekcioglu et al26 used OAA/S
Figure 3. Group VAS scores during the intraopera-
tive period (mean 6 standard error). *P 5 .005 and
.004; significant difference for Groups B and O
compared with Group M. VAS, Visual Anxiety Scale.
423
Figure 4. Group VAS scores during the postopera-
tive period (mean 6 standard error). *P 5 .001; signif-
icant difference when compared with the other two
groups. VAS, Visual Anxiety Scale.
scores and BIS values to assess the depth of seda-
tion in patients who had received spinal anesthesia
and reported a strong correlation between OAA/S
scores and BIS values. They also concluded that
OAA/S is a suitable alternative to BIS for the evalu-
ation of sedation during spinal anesthesia. In the
present study, we suggest that OAA/S is an
adequate and clinically appropriate test of seda-
tion levels. In our study, the mean age of 75
patients was 31 years, and preoperative, postoper-
ative, and intraoperative OAA/S scores were main-
tained at 5, 5, and 4 to 5 points, respectively,
without any significant difference between the
three groups. However, age groups were not taken
into consideration in the assessment of sedation.
Further studies are required to investigate the ef-
fects of music among different age groups.
VAS and STAI scales were used individually or in
combination to evaluate the effects of music on
anxiety.16,27 Lepage et al16 reported a moderate cor-
relation between STAI and VAS. Many studies re-
ported that listening to music led to a decrease in
anxiety levels, as evaluated via VAS and/or STAI
scores.11,28-32 However, studies by Gaberson33 and
Lepage et al16 found similar anxiety scores between
groups who listened or did not listen to music.
We also evaluated anxiety levels of patients using
STAI and VAS scoring systems in combination.
VAS scores during the postoperative period were
424 ILKKAYA ET AL

Table 3. Group STAI Scores (Mean ± Standard Error)

Measurement Time Points Group O (n 5 25) Group B (n 5 25) Group M (n 5 25) P
Preoperative STAI-TA 38.6 6 8.6 37.4 6 6.4 37.4 6 7.1 .783
Preoperative STAI-SA 36.1 6 7.7 37.5 6 7.4 36.7 6 8.7 .835
Prespinal STAI-SA 39.6 6 7.4 37.8 6 8.6 35.0 6 7.1 .116
5 min before surgery STAI-SA 40.5 6 6.1 37.7 6 4.4 34.6 6 7.5* .17
At 30 min of postoperative STAI-SA 32.2 6 4.6 30.9 6 8.7 28.0 6 6.2* .18
STAI-TA, State-Trait Anxiety Inventory-Trait Anxiety Inventory; STAI-SA, State-Trait Anxiety Inventory-State Anxiety
Inventory.
*Significant difference when compared with Group O.

significantly lower in the music and white noise
groups compared with the group exposed to the
background noise. In intragroup comparisons of
VAS scores measured in three groups at measure-
ment time points, a stepwise decrease in these
scores was noted, beginning from the preoperative
period and persisting until the end of the postoper-
ative period. Relatively higher preoperative VAS
values can be associated with patients’ unfamiliar-
ity with the OR and their concerns about the
method of spinal anesthesia. The lower anxiety
scores reported by patients who listened to their fa-
vorite music during the perioperative period
demonstrate that listening to music can effectively
ease patient anxiety during this process. Because of
its effect of masking other sounds and noises, white
noise is expected to induce a reduction in patient
anxiety levels as measured by VAS scores. However,
an alleviating effect was only observed during post-
operative period. Some other studies reported no
favorable effects of white noise on anxiety
scores.15,34 However, in our study, we are unable
to explain why white noise only showed a
favorable effect during the postoperative period.
In our study, no intergroup differences were found
between preoperative STAI-TA and the preopera-
tive and prespinal STAI-SA values. In the music
group, STAI-SA values measured at 5 minutes
preoperative and postoperative periods were
significantly lower than in the other two groups.
Intragroup comparisons showed higher preopera-
tive STAI-SA anxiety scores in the group of patients
who listened to music, but these scores decreased
stepwise during the intraoperative and postopera-
tive periods. The two patient groups that listened
to white noise or ambient noise showed lower
STAI-SA anxiety scores during the postoperative
period than during the preoperative and intraoper-
ative periods. We attribute this decrease to the
deep relaxation felt by patients because of the op-
eration’s termination.
In previous studies, markedly increased satisfac-
tion levels were reported by patients who had sur-
gery while listening to music, and most indicated
that they would prefer to listen to their favorite
music pieces if they were to undergo similar sur-
gery in the future.17,35 In our study, higher
patient satisfaction was expressed by the group
of patients who had surgery while music played
in the OR.
We note the following limitations of the present
study: the patients were not blinded as to group
membership, which may introduce bias. It would
have been interesting to include one group
without IV midazolam, and to truly evaluate the
magnitude of anxiolysis with music alone. In addi-
tion, in our study, ages of the patients were not

Table 4. Distribution of Cases Based on Patient Satisfaction

Group O (n 5 25) Group B (n 5 25) Group M (n 5 25)
Level of Satisfaction n (%)
Moderate 23 (92) 4 (16) 0 (0)
Good 2 (8) 18 (72) 2 (8)
Very good 0 (0) 3 (12) 23 (92)
THE EFFECTS OF MUSIC-NOISE ON SEDATION AND ANXIETY
taken into consideration in the evaluation of seda-
tion and anxiety.
Conclusion
When combined with IV midazolam infusion,
listening to music alleviates perioperative anxiety
and concerns and helps the patient through the
perioperative period with a happier and pleased
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