To Serenade or To Sedate? That is Still The Question - A Followup Trial On Anxiolytic Options Before Peripheral Nerve Blocks
Phase: PHASE1
Conditions: Peripheral Nerve Block, Anxiety, Preoperative Anxiety
Sponsor: University of Pennsylvania

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TO SERENADE OR TO SEDATE? THAT IS STILL THE QUESTION – A FOLLOWUP 
TRIAL ON ANXIOLYTIC OPTIONS BEFORE PERIPHERAL NERVE BLOCKS 
 
 
Principal Investigator  
Veena Graff MD 
Department of Anesthesiology & Critical Care 
51 North 39th Street, 223 Wright-Saunders 
Philadelphia, PA 19104 
Tel: (215) 662-8244 | Fax: (215) 243-3234 | Cell: (570) 730-1350 
Sub Investigator 
Nabil M Elkassabany MD, MSCE 
Lu Cai MD 
Ignacio Badiola MD 
Department of Anesthesiology & Critical Care 
Study Product 
Patient choice of music 
 
IRB Number 
 
 
 
Initial version 
1.0 
Date 
31 January 2020 

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Table of Contents 
BACKGROUND AND STUDY RATIONALE ................................................................................................ 6 
1 
INTRODUCTION .................................................................................................................................. 6 
1.1 
BACKGROUND AND RELEVANT LITERATURE ..................................................................................... 6 
2 
STUDY OBJECTIVES ......................................................................................................................... 7 
2.1 
PRIMARY OBJECTIVE ...................................................................................................................... 7 
2.2 
SECONDARY OBJECTIVES (IF APPLICABLE) ...................................................................................... 7 
3 
INVESTIGATIONAL PLAN .................................................................................................................. 7 
3.1 
GENERAL DESIGN .......................................................................................................................... 7 
3.2 
ALLOCATION TO INTERVENTIONAL GROUP [IF APPLICABLE] ............................................................... 7 
3.3 
STUDY MEASURES ......................................................................................................................... 7 
3.4 
STUDY ENDPOINTS......................................................................................................................... 9 
3.4.1 
Primary Study Endpoints ......................................................................................................... 9 
3.4.2 
Secondary Study Endpoints .................................................................................................... 9 
4 
STUDY POPULATION AND DURATION OF PARTICIPATION ........................................................ 9 
4.1 
DURATION OF STUDY PARTICIPATION .............................................................................................. 9 
4.2 
TOTAL NUMBER OF SUBJECTS AND SITES........................................................................................ 9 
4.3 
INCLUSION CRITERIA ...................................................................................................................... 9 
4.4 
EXCLUSION CRITERIA ................................................................................................................... 10 
4.5 
SUBJECT RECRUITMENT ............................................................................................................... 10 
4.6 
VULNERABLE POPULATIONS: ........................................................................................................ 10 
5 
STUDY PROCEDURES ..................................................................................................................... 10 
5.1 
SCREENING ................................................................................................................................. 10 
5.2 
STUDY INTERVENTION OR OBSERVATIONAL PHASE (GIVE THIS SECTION A NAME THAT IS RELEVANT TO 
THE DESIGN OF YOUR STUDY)..................................................................... ERROR! BOOKMARK NOT DEFINED. 
5.2.1 
Visit 1 (sometimes referred to as the baseline visit).............................................................. 10 
5.2.2 
Visit 2 ....................................................................................... Error! Bookmark not defined. 
5.2.3 
Visit 3 ....................................................................................... Error! Bookmark not defined. 
5.2.4 
Visit X (If applicable for your study) ......................................... Error! Bookmark not defined. 
5.2.5 
End of Study Visit .................................................................... Error! Bookmark not defined. 
5.3 
UNSCHEDULED VISITS .................................................................. ERROR! BOOKMARK NOT DEFINED. 
5.4 
SUBJECT WITHDRAWAL ................................................................................................................ 11 
5.4.1 
Data Collection and Follow-up for Withdrawn Subjects ........................................................ 11 
5.5 
EARLY TERMINATION VISITS ......................................................... ERROR! BOOKMARK NOT DEFINED. 
5.6 
EFFICACY EVALUATIONS (ONLY IF APPLICABLE) .............................. ERROR! BOOKMARK NOT DEFINED. 
5.7 
PHARMACOKINETIC EVALUATION (ONLY IF APPLICABLE) .................. ERROR! BOOKMARK NOT DEFINED. 
5.8 
GENETIC TESTING (ONLY IF APPLICABLE) ....................................... ERROR! BOOKMARK NOT DEFINED. 
5.9 
SAFETY EVALUATION (ONLY IF APPLICABLE) ................................................................................... 11 
6 
STATISTICAL PLAN ......................................................................................................................... 11 
6.1 
SAMPLE SIZE AND POWER DETERMINATION ................................................................................... 11 
6.2 
STATISTICAL METHODS ................................................................................................................ 11 
6.3 
CONTROL OF BIAS AND CONFOUNDING (IF APPLICABLE, TYPICALLY OBSERVATIONAL STUDY OR IF 
RANDOMIZATION IS NOT TAKING PLACE) ...................................................... ERROR! BOOKMARK NOT DEFINED. 
6.3.1 
Baseline Data ........................................................................................................................ 11 
6.3.2 
Analysis of Primary Outcome of Interest ............................................................................... 11 
6.3.3 
Pharmacokinetic Analysis (only if applicable) ......................... Error! Bookmark not defined. 
6.3.4 
Interim Analysis ....................................................................... Error! Bookmark not defined. 
7 
SAFETY AND ADVERSE EVENTS ................................................................................................... 12 
7.1 
DEFINITIONS ................................................................................................................................ 12 
7.1.1 
Adverse Event ....................................................................................................................... 12 

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7.1.2 
Serious Adverse Event .......................................................................................................... 12 
7.2 
RECORDING OF ADVERSE EVENTS ................................................................................................ 12 
7.3 
RELATIONSHIP OF SAE TO STUDY ................................................................................................ 12 
7.4 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS ................................. 12 
7.4.1 
Follow-up Report ................................................................................................................... 13 
7.4.2 
Investigator reporting: notifying the study sponsor (if applicable)Error! 
Bookmark 
not 
defined. 
7.4.3 
Data and Safety Monitoring Plan........................................................................................... 13 
8 
STUDY ADMINISTRATION, DATA HANDLING AND RECORD KEEPING .................................... 13 
8.1 
CONFIDENTIALITY ......................................................................................................................... 13 
8.2 
DATA COLLECTION AND MANAGEMENT .......................................................................................... 13 
8.3 
RECORDS RETENTION .................................................................................................................. 13 
9 
STUDY MONITORING, AUDITING, AND INSPECTING .................................................................. 13 
9.1 
STUDY MONITORING PLAN ............................................................................................................ 13 
9.2 
AUDITING AND INSPECTING ........................................................................................................... 14 
10 
ETHICAL CONSIDERATIONS .......................................................................................................... 14 
10.1 
RISKS .......................................................................................................................................... 14 
10.2 
BENEFITS .................................................................................................................................... 14 
10.3 
RISK BENEFIT ASSESSMENT ......................................................................................................... 14 
10.4 
INFORMED CONSENT PROCESS / HIPAA AUTHORIZATION .............................................................. 14 
10.4.1 
Alterations to Typical Consent Process (only include if applicable)Error! Bookmark not 
defined. 
11 
STUDY FINANCES ............................................................................................................................ 14 
11.1 
FUNDING SOURCE ........................................................................................................................ 14 
11.2 
CONFLICT OF INTEREST ................................................................................................................ 14 
11.3 
SUBJECT STIPENDS OR PAYMENTS ............................................................................................... 14 
12 
PUBLICATION PLAN ............................................................. ERROR! BOOKMARK NOT DEFINED. 
13 
REFERENCES ................................................................................................................................... 15 
14 
ATTACHMENTS ..................................................................... ERROR! BOOKMARK NOT DEFINED. 
15 
APPENDICES ......................................................................... ERROR! BOOKMARK NOT DEFINED. 
15.1 
EXAMPLE: TABLE 1: SCHEDULE OF STUDY PROCEDURES ............ ERROR! BOOKMARK NOT DEFINED. 
15.2 
STUDIES INVOLVING RESEARCH MRIS .......................................... ERROR! BOOKMARK NOT DEFINED. 
15.3 
STUDIES INVOLVING RESEARCH RADIATION ................................... ERROR! BOOKMARK NOT DEFINED. 
15.4 
STUDIES INVOLVING RESEARCH CT SCANS ................................... ERROR! BOOKMARK NOT DEFINED. 
15.5 
STUDIES INVOLVING NUCLEAR MEDICINE REGULATED RESEARCH PROCEDURESERROR! 
BOOKMARK 
NOT DEFINED. 
15.6     RESEARCH STUDIES INVOLVING PATHOLOGY AND LAB MEDICINE…………………………………….. 20 
15.7      REFERENCE FOR SAFETY REPORTING SECTION- COMMON DEFINITIONS FOR DEVELOPING ADVERSE 
EVENT TRACKING AND SERIOUS ADVERSE EVENT REPORTING PROTOCOL  
15.8 
SOURCE DOCUMENTS .................................................................. ERROR! BOOKMARK NOT DEFINED. 
15.9 
CASE REPORT FORMS (CRFS) ..................................................... ERROR! BOOKMARK NOT DEFINED. 
 

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Study Summary 
 
Title 
TO SERENADE OR TO SEDATE? THAT IS STILL THE 
QUESTION – A FOLLOWUP TRIAL ON ANXIOLYTIC 
OPTIONS BEFORE PERIPHERAL NERVE BLOCKS 
Short Title 
TO SERENADE OR TO SEDATE? 
IRB Number 
 
Methodology 
A prospective, randomized controlled study 
Study Duration 
One year 
Study Center(s) 
Single-center, ambulatory surgical center, at a university hospital 
Objectives 
Primary: 
• 
To compare the change in preoperative anxiety scores between study 
groups from after to before placement of a peripheral nerve block. 
Secondary: 
• 
To evaluate differences in hemodynamics, block times, patient 
satisfaction scores, provider satisfaction scores, evaluation difficulty in 
communication between provider and patient, and adverse effects 
between both study groups  
Number of Subjects 
160 

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Main Inclusion and 
Exclusion Criteria 
Inclusion:  patients who are >18 years of age who are able to give informed 
consent who are scheduled to receive any type of peripheral nerve block either 
for their primary anesthetic or for postoperative pain control in the preoperative 
bay at the ambulatory surgical center. 
Exclusion:  patients who have an associated significant psychiatric disorder 
such as generalized anxiety disorder, panic disorder, depression, psychosis, 
bipolar disorder; individuals who were incompetent to give informed consent; 
pregnant and/or breast feeding patients; any underlying coagulopathy, 
infection or other factors which would be a contraindication to receiving a 
peripheral nerve block; hypersensitivity to midazolam; and history of renal 
impairment. Patients who were extremely anxious (scores 50 and greater on 
the State Trait Anxiety Inventory-6 (STAI-6) tool) as these patients typically 
require pharmacologic therapy to help reduce their anxiety and may confound 
the results of the study. 
Intervention  
There will be two study groups who will be randomized. 1. Music group: Music 
group – patients will select music of their choice to be played via non-noise 
canceling headphones. 2. Midazolam group:  patients in this group will receive 
IV midazolam (1mg to 2mg max) after the golden moment has been 
completed. 
 
In our daily practice, it is the provider’s preference to give patients medication 
for sedation while conducting the preoperative nerve block. Patients do not 
routinely get sedation medication during the preoperative nerve block 
placement. 
Statistical 
Methodology 
1:1 Randomized controlled study 
Data and Safety 
Monitoring Plan  
The PI, Dr. Graff and her MD collaborator Dr. Nabil Elkassabany will be 
responsible for data safety and monitoring. All data will be kept in a locked 
cabinet in the MD collaborator’s office. The PI and collaborators will perform 
safety reviews after 25 subjects are enrolled. Any protocol-related problem or 
deviation will be reported to Dr. Graff and/or Dr. Nabil Elkassabany as soon as 
possible.  
 

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Background and Study Rationale 
1 
Introduction 
This document is a research protocol and the described study will be conducted in compliance with the 
provisions set forth in the protocol as well as, Good Clinical Practice standards, associated federal 
regulations, and all applicable University research requirements.  
 
Preoperative anxiety is common and can adversely affect a patient’s perioperative course by elevating 
stress markers, promoting fluctuations in hemodynamics and negatively impacting on postoperative 
recovery.1 Preoperative anxiety is routinely treated with pharmacologic agents such as midazolam, a 
benzodiazepine, which has known, undesirable side effects including respiratory depression, 
hemodynamic perturbations, and paradoxical effects such as hostility, aggression, and psychomotor 
agitation.2,3 The use of sedative medications requires continuous vital sign monitoring of patients by either 
anesthesia or nursing personnel and there is a question of whether midazolam helps reduce pre-
procedural anxiety compared with placebo. Music is a non-pharmacologic intervention that has been 
shown to significantly decrease preoperative anxiety.1,4–6 This intervention can be used as an adjunct or 
even replace pharmacologic agents to help with preoperative anxiety. Music is a modality that is virtually 
harm-free and relatively cheap in cost. Patients who are unable to tolerate pharmacologic agents to treat 
preoperative anxiety can greatly benefit from non-pharmacologic options such as music. 
 
Regional anesthesia procedures such as an ultrasound guided, peripheral nerve block is a common 
bedside procedure done preoperatively. Patients may have some anxiety prior to the administration of 
this nerve block procedure and may receive sedation for it. However, it is imperative not to over sedate 
them as constant feedback from the patient is necessary during the procedure. Commonly, midazolam is 
used to reduce this anxiety, but non-pharmacologic therapies can also reduce anxiety.1,5 In our recent 
published study, we evaluated the use of research-selected, relaxing music, to reduce anxiety before the 
nerve block is administered.7 In this study, we used noise-canceling headphones and played research-
selected music as our anxiolytic music modality and compared this with midazolam.7 The findings showed 
no difference between both groups in the change in anxiety scores from after to before the nerve block, 
however patients had better satisfaction in the midazolam group and increased difficulty in 
communication in the music group. We attributed this to not allowing patients to choose their own 
selection of music and the use of noise-canceling headphones.    
 
Therefore, in this follow-up study, we aim to evaluate the use of patient-selected music via non-noise 
canceling headphones as a preoperative anxiolytic prior to the administration of a bedside, peripheral 
nerve block procedure. This study will be conducted at an ambulatory surgical center in a university 
setting. 
1.1 
Background and Relevant Literature  
 
Patients often feel a tremendous amount of anxiety prior to their planned surgical procedure and 
anesthetic. As a result, this can affect their perioperative period by elevating their stress markers, causing 
various fluctuations in their hemodynamics, and poorly impacting their postoperative recovery.1 A 
significant number of patients have anxiety about the anticipation in their overall outcome and 
postoperative pain control.2,3 To treat preoperative anxiety, pharmacologic agents such as short-acting 
benzodiazepines and opioids are used as needed depending on an individual basis; however, there are 
known significant side effects from these medications such as respiratory depression, vital sign 
abnormalities, and possible apnea which limit the use of these medications and in some instances, 
prevent the use for preoperative anxiety. In addition to this, utilization of these medications for conscious 
sedation also require continuous monitoring of a patient by either anesthesia personnel or nursing staff. 
 
Music is a non-pharmacologic intervention that has been shown to significantly decrease preoperative 
anxiety.1,4,6 This intervention can be used as an adjunct or even replace pharmacologic agents to help 
with preoperative anxiety1. Music is a modality that is virtually harm-free and relatively cheap in cost. 
Patients who are unable to tolerate pharmacologic agents to treat preoperative anxiety can greatly benefit 
from non-pharmacologic options such as music. 

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The Speilberger’s validated tool, the State Trait Anxiety Inventory (STAI), is one of the best measured 
tools to evaluate preoperative anxiety. The STAI has been referred to as the “gold standard” in properly 
evaluating preoperative anxiety.8 There are two components to this tool; a state portion which evaluates 
the current state of anxiety a patient has in a clinical setting, and a trait portion which evaluates how the 
patient generally feels unrelated to the clinical setting. Each of these sections have 20 items to answer 
and approximately takes 10-15 minutes to complete. In preoperative anxiety testing, the STAI-S is 
commonly used in research to properly evaluate the level of preoperative anxiety in the current clinical 
setting. Marteau and her colleagues have developed a shortened STAI version, the STAI-6, that has also 
been validated.8 The shortened STAI-6 tool has six questions and may be more beneficial to use in a high 
turnover, ambulatory surgical center setting as it only takes a few minutes to complete. 
 
We will be using the STAI-6 short form questionnaire to score the preoperative anxiety levels in our 
patient population.  
 
2 
Study Objectives 
2.1 
Primary Objective 
To determine preoperative anxiety score differences between patients who receive music vs IV 
midazolam during their preoperative nerve block placement. 
2.2 
Secondary Objectives (if applicable) 
To evaluate differences in hemodynamics, block times, patient satisfaction scores, provider satisfaction 
scores, evaluation difficulty in communication between provider and patient, and adverse effects between 
both study groups  
3 
Investigational Plan  
3.1 
General Design 
This will be a prospective, randomized controlled study. Participants will be randomized to receiving 
research-selected music versus IV midazolam (1mg to 2mg max) during their preoperative peripheral 
nerve block placement.  
3.2 
Allocation to Interventional Group [if applicable] 
Subjects will be randomized to either music or IV midazolam. Subjects will be randomized in a one to one 
fashion and the randomization will take place using a computer-generated algorithm.  
3.3 
Study Measures 
There will be two study groups who will be randomized. 1. Music group – patients will select their choice 
of music via non-noise canceling headphones. 2. Midazolam group:  patients in this group will receive IV 
midazolam (1mg to 2mg max) after the golden moment has been completed.  
 
A pre-anxiety score will be obtained using the STAI-6 validated tool after the patient has signed the 
informed consent. After the golden moment is completed, the intervention will start. Once the nerve block 
is completed, a post anxiety score will be obtained using STAI-6 validated tool.  
 
For our primary outcome measure, we will use the short form of the state scale of the Spielberger State-
Trait Anxiety Inventory (STAI-6) to measure pre procedure and post procedure anxiety levels (see below). 
The shortened STAI-6 tool has six questions and may be more beneficial to use in a high turnover, 
ambulatory surgical center setting as it only takes a few minutes to complete. In the original 20-item STAI-
State tool, the scores range from 20 to 80. A score greater than 50 on the original 20-item scale is 
associated with a high level of anxiety. The population normal score is approximately 35 (Speilberger 
1983). In the STAI-6 tool, there are six questions with a Likert scale from 1 to 4. This gives a score range 

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from 6 to 24. To create scores compatible with the original STAI-S scores, the STAI-6 scores will be 
divided by 6 and multiplied by 20 to give a range from 20 to 80. 
 
 
 
For our secondary outcome measure, we will obtain the following information: 
 
1.  Patient satisfaction scores using a 10-point visual analogue scale (VAS) as follows: 
 
“Using any number from 0 to 10, where 0 is the WORST experience possible and 10 is the BEST 
experience possible, what number would you use to rate your overall preoperative experience while 
getting a peripheral nerve block placed?” 
 
 
 
 
 
 
 
 
 
2. Provider satisfaction scores using a 10-point visual analogue scale (VAS) as follows: 
 
 “Using any number from 0 to 10, where 0 is the WORST experience possible and 10 is the BEST 
experience possible, what number would you use to rate your overall preoperative experience while 
placing a peripheral nerve block for your patient?” 
 
 
 
 
 
 
 
 
 
3. Evaluation of communication difficulties between provider and patient by asking one question on 
a 5-point Likert scale: 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
WORST 
BEST 
0 
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
WORST 
BEST 

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From provider to patient: 
“I found it difficult to communicate with the patient while doing the preoperative nerve block.” 
A. Strongly Disagree 
B. Disagree 
C. Neutral 
D. Agree 
E. Strongly Agree 
 
From patient to provider: 
“I found it difficult to communicate with the physician while the preoperative nerve block was being 
done on me.” 
A. Strongly Disagree 
B. Disagree 
C. Neutral 
D. Agree 
E. Strongly Agree 
 
 
3.4 
Study Endpoints  
3.4.1 Primary Study Endpoint 
The primary end point will be to determine change in the anxiety scores using the STAI-6 tool between 
the music group and the IV midazolam group. 
3.4.2 Secondary Study Endpoints 
The secondary end points will be to determine any differences in patient satisfaction scores, provider 
satisfaction scores, evaluation of difficulties in communication between provider and patient, 
hemodynamics, block times, and adverse effects including paresthesia’s, patchy block, failed block, and 
serious adverse effects including bleeding, infection, paralysis, local anesthetic systemic toxicity between 
both groups. 
 
4 
Study Population and Duration of Participation  
The study population will include patients who are >18 years of age, who will give informed consent in 
receiving a peripheral nerve block in the preoperative bay for their primary anesthetic and/or for their 
postoperative pain control. 
 
We will exclude the following: patients who have an associated significant psychiatric disorder such as 
anxiety, panic disorder, depression, psychosis, or bipolar disorder; patients who are unable to give 
informed consent; patients who are pregnant; patients who have an underlying coagulopathy and 
infection. 
4.1 
Duration of Study Participation  
The study duration will be from the time informed consent occurs to after the perioperative block has been 
completed. Once the post-anxiety STAI-6 score has been obtained, the study is complete. 
4.2 
Total Number of Subjects and Sites  
Total number of subjects will be 160; 80 in the music group and 80 in the IV midazolam group. Study will 
take place at Penn Medicine University City, PMUC. 
4.3 
Inclusion Criteria 
Patients who are >18 years of age, who will give informed consent in receiving a peripheral nerve block in 
the preoperative bay for their primary anesthetic and/or for their postoperative pain control. 

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4.4 
Exclusion Criteria 
We will exclude the following: patients who have an associated significant psychiatric disorder such as 
generalized anxiety disorder, panic disorder, depression, psychosis, bipolar disorder; individuals who 
were incompetent to give informed consent; pregnant and/or breast feeding patients; any underlying 
coagulopathy, infection or other factors which would be a contraindication to receiving a peripheral nerve 
block; hypersensitivity to midazolam; and history of renal impairment. Patients who were extremely 
anxious (scores 50 and greater on the State Trait Anxiety Inventory-6 (STAI-6) tool) 
4.5 
Subject Recruitment  
All patients will be screened initially at the preoperative surgical clinic visit. Any patient that cannot be 
reached will be approached in the preoperative bay during the preoperative period of their planned 
surgery. Subjects will be given the details about the study and given adequate time to read the consent 
form and talk the study over with family that accompanies them. 
4.6 
Vulnerable Populations:  
Children, pregnant women, fetuses, neonates, or prisoners are not included in this research study. 
5 
Study Procedures  
5.1 
Screening  
The general flow of the study will be conducted as follows: 
1. Research coordinator will call or approach patients who are scheduled for a surgical 
procedure that is planning for a peripheral nerve block either for the primary anesthetic or for 
postoperative pain control to be placed in the preoperative bay in the ambulatory surgical 
center. 
2. Research coordinator will discuss the purpose of our study and explain the study in detail for 
the patient. If a patient agrees to participate, then we will have the patient sign the informed 
consent for the study.  
5.1.1 Visit 
3. Once the patient signs the informed consent for the peripheral nerve block by anesthesia 
team. The patient randomized will be revealed to either music or IV midazolam. The pre-
procedure anxiety score will then be obtained using the STAI-6 validated tool. 
4. The golden moment will be conducted between the patient, provider, and nursing staff. Once 
this golden moment is completed, the anxiolytic intervention will start (music or IV 
midazolam)* 
5. The preoperative nerve block will be conducted by the regional anesthesia block team. 
6. Once the nerve block is completed, the post-procedure anxiety score will be obtained, and 
we will also obtain the patient satisfaction score, the provider satisfaction score, and the 
evaluation of any difficulties in communication between the provider and patient. After these 
questions have been obtained, the study is complete. 
 
A minimum of 1mg and a maximum of 2mg of IV midazolam will be given in the IV midazolam group. 
 
Peripheral nerve blocks are conducted under ultrasound guidance according to standard practice at 
PMUC. 
 
Vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation are routinely 
obtained as a part of standard of care if sedation medication is used and when peripheral nerve blocks 
are placed. 
 

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Starting block time and ending block time are routinely obtained as a part of the patient record.  
 
 
During this entire process, patient demographics, hemodynamics (heart rate, blood pressure, oxygen 
saturation, and respiratory rate), block times (start and end time), and any adverse effects including 
paresthesia’s, patchy block, failed block, and serious adverse effects including bleeding, infection, 
paralysis, local anesthetic systemic toxicity will be recorded as the routine part of practice. 
5.2 
Subject Withdrawal  
Subjects may withdraw from the study at any time without impact to their care. They may also be 
discontinued from the study at the discretion of the Investigator for lack of adherence to intervention or 
study procedures or AEs. It will be documented whether or not each subject completes the study. 
5.2.1 Data Collection and Follow-up for Withdrawn Subjects 
Data will still be collected for subjects who withdrawal from the study. In cases where subjects wish to 
withdrawn PHI consent they will be able to do so by telling a study team member in person or through 
information provided on the ICF. 
5.3 
Safety Evaluation 
When evaluating safety, the doctors will look at any reported AE’s as well as patients who are unwilling or 
unable to adhere to the randomized allocation. If patients in either group have more than 25% deviation 
rate the inclusion and exclusion as well as block method will be reevaluated to better limit deviations. 
 
6 
Statistical Plan 
6.1 
Sample Size and Power Determination 
Based on a previous study by Bringman et.al.  the mean (SD) of STAI anxiety score is  34(8). 5A clinically 
meaningful decrease, as determined by the Cochrane review group was 0.5 of SD.1,5 Our sample size 
calculation to detect a 4-point change in pain score (p less than 0.05 significance level) was 64 patients 
(α=0.05, power=80%). We will inflate out sample size by 25% to account for any missing data or any 
withdrawal from the study; therefore, our estimated sample size will be 80 patients per group. 
6.2 
Statistical Methods 
Statistical analyses will be performed using STATA 13 statistical software (Dallas, TX). Demographic or 
other categorical data will be analyzed using T test or Fishers exact test as appropriate. Repeated 
measurements (STAI-6 scores) will be analyzed by using the t-test or Mann-Whitney U-test as 
appropriate. Normally distributed data will be presented as means ± SE of the mean (SEM), non-normally 
distributed data are presented as medians ± quartiles (interquartile range) and categorical data will be 
presented as raw data and as frequencies. The alpha level for all analyses was set as P less than 0.05. 
6.2.1 Baseline Data 
Demographic or other categorical data will be analyzed using T test or Fishers exact test as appropriate. 
6.2.2 Analysis of Primary Outcome of Interest 
Repeated measurements (STAI-6 scores) will be analyzed by using the t-test or Mann-Whitney U-test as 
appropriate. 
 

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7 
Safety and Adverse Events 
This section provides the safety management plans for the study. This section should be consistent with 
the Penn IRB guidelines tailored to the requirements specific for each study. It should describe how 
safety reporting will be monitored and take place over the course of the trial.  
7.1 
Definitions 
7.1.1 Adverse Event 
Study definition of an adverse event (AE). Can include the Penn IRB definition of an adverse event unless 
there are some differences in the adverse event definitions for this particular study. Standard definition of 
an adverse event as follows: 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in severity 
during the course of the study.  Intercurrent illnesses or injuries should be regarded as adverse events.  
Abnormal results of diagnostic procedures are considered to be adverse events if the abnormality: 
• 
results in study withdrawal 
• 
is associated with a serious adverse event 
• 
is associated with clinical signs or symptoms 
• 
leads to additional treatment or to further diagnostic tests 
• 
is considered by the investigator to be of clinical significance 
7.1.2 Serious Adverse Event 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  A serious adverse event is any AE that is:  
• 
fatal 
• 
life-threatening 
• 
requires or prolongs hospital stay 
• 
results in persistent or significant disability or incapacity 
• 
required intervention to prevent permanent impairment or damage 
• 
a congenital anomaly or birth defect 
• 
an important medical event 
7.2 
Recording of Adverse Events 
Information on all adverse events will be recorded immediately in the source document, and also in the 
appropriate adverse event module of the case report form (CRF).  All clearly related signs, symptoms, 
procedures results will be recorded in the source document. 
 
All adverse events occurring during the study period will be recorded.  The clinical course of each event 
will be followed until resolution, stabilization, or until it has been determined that the study intervention or 
participation is not the cause.  Serious adverse events that are still ongoing at the end of the study period 
will be followed up to determine the final outcome.  Any serious adverse event that occurs after the study 
period and is considered to be possibly related to the study intervention or study participation will be 
recorded and reported. 
7.3 
Relationship of AE to Study  
The PI will supervise the assessment of relationship of each adverse even to the study procedures. The 
adverse events, if such occurs, will be classified as definitely related, probably related, possibly related, 
unlikely or unrelated. 
7.4 
Reporting of Adverse Events and Unanticipated Problems 
The Investigator will promptly notify the Penn IRB of all on-site unanticipated, Adverse Events that are 
related to the research activity. Other unanticipated problems related to the research involving risk to 

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subjects or others will also be reported promptly. Written reports will be filed using the HS-ERA and in 
accordance with the Penn IRB timeline of 10 working days. 
7.4.1 Follow-up Report 
If an AE has not resolved at the time of the initial report and new information arises that changes the 
investigator’s assessment of the event, a follow-up report including all relevant new or reassessed 
information (e.g., concomitant medication, medical history) should be submitted to the IRB. The 
investigator is responsible for ensuring that all SAEs are followed until either resolved or stable. 
7.4.2 Data and Safety Monitoring Plan 
The PI, Dr. Graff and her collaborator Dr. Nabil Elkassabany will be responsible for data safety and 
monitoring. All paper data will be kept in a locked cabinet in the MD collaborator’s office. The PI and 
collaborators will perform safety reviews after 25 patients are enrolled. Any protocol-related problem or 
deviation will be reported to Dr. Graff and/or Dr. Nabil Elkassabany as soon as possible. 
 
8 
Study Administration, Data Handling and Record Keeping 
8.1 
Confidentiality 
Information about study subjects will be kept confidential and managed according to the requirements of 
the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Those regulations require a 
signed subject authorization informing the subject of the following:  
• 
What protected health information (PHI) will be collected from subjects in this study 
• 
Who will have access to that information and why 
• 
Who will use or disclose that information 
• 
The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, 
retains the ability to use all information collected prior to the revocation of subject  
Study date will be stored on a Penn institutionally secured and managed server specific to the 
Anesthesiology Department in a locked folder only for this protocol.  
8.2 
Data Collection and Management  
Demographic information will be collected from patient charts. Information about sedation onset, block 
start and stop as well as survey information will be captured on paper that will be stored on Penn campus 
in secured building in locked office in locked filing cabinets. Subjects will be given a study number at time 
of enrollment. De-identified data will be inputted into a department and folder password secured excel 
sheet. 
Once study analysis is complete identifiable information linking subject to study number will be destroyed/ 
deleted. 
8.3 
Records Retention 
Records will be retained up to 3 years after the completion of research. Electronic records of directly 
collected data will subsequently be destroyed from electronic server. 
 
9 
Study Monitoring, Auditing, and Inspecting 
9.1 
Study Monitoring Plan 
The study will be monitored by Dr. Graff and Dr. Elkassabany. 

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9.2 
Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB, government 
regulatory bodies, and University compliance and quality assurance groups of all study related 
documents (e.g. source documents, regulatory documents, data collection instruments, study data etc.).  
The investigator will ensure the capability for inspections of applicable study-related facilities. 
10 Ethical Considerations 
Study will be submitted to the Penn IRB for approval before study enrollment begins. Any changes to the 
protocol will we preapproved by the IRB before any changes to study practice is made. 
10.1 
Risks 
The risks of the study are related to the administration of midazolam which include tenderness and pain 
during injection at IV site. This risk is addressed in the local block consent form and thus is not putting 
subjects at a greater risk. 
10.2 
Benefits 
The individual subjects may not receive any benefit from participating in this study. Potential benefit could 
be increased relaxation and lower anxiety from music sedation or midazolam. For the study population 
this study hopes to prove that non medicinal sedation is adequate for subject comfort and a decrease in 
anesthetics can be achieved. 
10.3 
Risk Benefit Assessment 
The potential benefits are greater to the limited risks for patients thus this study should be conducted. 
10.4 
Informed Consent Process / HIPAA Authorization  
All subjects for this study will be provided a consent form describing this study providing sufficient 
information for subjects to make an informed decision about their participation in this study.  This consent 
form will be submitted with the protocol for review and approval by the IRB for the study.  The formal 
consent of a subject, using the IRB-approved consent form, must be obtained before that subject 
undergoes any study procedure.  The subject, must sign the consent form, and the investigator-
designated research professional obtaining the consent. Subjects will be consented by the study Principal 
Investigator, or appropriate designee, in perioperative holding room assigned at check in. Potential 
subjects will review the consent form in detail with the person designated to consent (either PI or CRC) 
and have the ability to review consent with family or friends that accompanied them to PMUC.  
 
11 Study Finances 
11.1 
Funding Source 
This study is not funded. 
11.2 
Conflict of Interest 
No conflicts of interest have been noted by initial study team if conflict arises the IRB will be notified 
according to regulations. All University of Pennsylvania Investigators will follow the University of 
Pennsylvania Policy on Conflicts of Interest Related to Research.  
11.3 
Subject Stipends or Payments 
Subjects will not be paid for study. 
 

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12 References 
1.  Bradt J, Dileo C, Shim M. Music interventions for preoperative anxiety. Cochrane Anaesthesia, 
Critical and Emergency Care Group, ed. Cochrane Database of Systematic Reviews. June 2013. 
doi:10.1002/14651858.CD006908.pub2 
2.  Maranets I, Kain ZN. Preoperative Anxiety and Intraoperative Anesthetic Requirements: Anesthesia 
& Analgesia. 1999;89(6):1346. doi:10.1097/00000539-199912000-00003 
3.  Kain ZN, Sevarino F, Alexander GM, Pincus S, Mayes LC. Preoperative anxiety and postoperative 
pain in women undergoing hysterectomy. Journal of Psychosomatic Research. 2000;49(6):417-422. 
doi:10.1016/S0022-3999(00)00189-6 
4.  Hole J, Hirsch M, Ball E, Meads C. Music as an aid for postoperative recovery in adults: A systematic 
review 
and 
meta-analysis. 
The 
Lancet. 
2015;386(10004):1659-1671. 
doi:10.1016/S0140-
6736(15)60169-6 
5.  Bringman H, Giesecke K, Thörne A, Bringman S. Relaxing music as pre-medication before surgery: 
A randomised controlled trial. Acta Anaesthesiologica Scandinavica. 2009;53(6):759-764. 
doi:10.1111/j.1399-6576.2009.01969.x 
6.  Gooding L, Swezey S, Zwischenberger JB. Using Music Interventions in Perioperative Care: 
Southern Medical Journal. 2012;105(9):486-490. doi:10.1097/SMJ.0b013e318264450c 
7.  Graff V, Cai L, Badiola I, Elkassabany NM. Music versus midazolam during preoperative nerve block 
placements: A prospective randomized controlled study. Reg Anesth Pain Med. 2019;44(8):796-799. 
doi:10.1136/rapm-2018-100251 
8.  Marteau TM, Bekker H. The development of a six-item short-form of the state scale of the Spielberger 
State-Trait Anxiety Inventory (STAI). British Journal of Clinical Psychology. 1992;31(3):301-306. 
doi:10.1111/j.2044-8260.1992.tb00997.x