Comparison on the Effectiveness of Intravenous Magnesium Sulphate and Intravenous Dexmedetomidine in Reducing Emergence Agitation in Adults Undergoing Otorhinolaryngology Surgery
Phase: PHASE4
Conditions: Adults Undergoing Otorhinolaryngology Surgery
Sponsor: Indonesia University

 
 
 
 
 
UNIVERSITY OF INDONESIA 
 
COMPARISON BETWEEN INTRAVENOUS MAGNESIUM 
SULFATE ADMINISTRATION WITH INTRAVENOUS 
DEXMEDETOMIDINE TO REDUCE CONSCIOUS 
RECOVERY AGITATION IN ADULT PATIENTS 
UNDERGOING OTORHINOLARYNGOLOGY SURGERY  
 
RESEARCH PROPOSAL  
 
 
Dr. dr. Riyadh Firdaus, Sp.An-TI, Subsp. NA(K) 
Version 01 dated January 26, 2026 
 
 
FACULTY OF MEDICINE  
SPECIALIST DOCTOR EDUCATION PROGRAM-1  
ANESTHESIOLOGY AND INTENSIVE THERAPY 
JAKARTA 2026

 
 
 
 
 

 
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VERIFICATION PAGE 
 
 
This proposal has been examined and approved by the Head of Study 
Program (KPS) 
Department of Anesthesiology and Intensive Therapy Faculty of Medicine 
University of Indonesia 
 
 
 
Knowing,   
Head of Study Program 
 
 
 
 
dr. Adhrie Sugiarto, Sp.An-TI, Subsp.-TI(K)

 
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VERIFICATION PAGE 
 
 
This proposal has been examined and approved by the Research and 
Development Coordinator (Kalitbang) of the Department of Anesthesiology 
and Intensive Therapy, Faculty of Medicine Indonesia 
 
 
 
Knowing,   
Research and Development Coordinator 
 
 
Dr. Jefferson, Sp.An-TI, Subsp. AKV(K)

 
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TABLE OF CONTENTS 
VERIFICATION PAGE ....................................................................................................... iii 
ORIGINALITY STATEMENT PAGE.......................... Error! Bookmarks are not specified. 
VERIFICATION PAGE ................................................. Error! Bookmarks are not specified. 
TABLE OF CONTENTS ....................................................................................................... vi 
TABLE LIST ........................................................................................................................... ix 
IMAGE LIST ........................................................................................................................... x 
LIST OF ATTACHMENTS................................................................................................... xi 
ABBREVIATION LIST ........................................................................................................xii 
CHAPTER 1 ........................................................................................................ INTRODUCTION
 
1 
1.1 
Background ................................................................................................................. 1 
1.2 
Problem Formulation................................................................................................... 2 
1.3 
Research Questions ..................................................................................................... 3 
1.4 
Research Hypothesis ................................................................................................... 3 
1.5 
Research Objectives .................................................................................................... 4 
1.5.1 
General Purpose ................................................................................................... 4 
1.5.2 
Special Purpose .................................................................................................... 4 
1.6 
Research Benefits ........................................................................................................ 5 
1.6.1 
Scientific Benefits ................................................................................................ 5 
1.6.2 
Clinical Benefits................................................................................................... 5 
1.6.3 
Benefits of Community Service ........................................................................... 5 
CHAPTER 2LITERATURE 
REVIEW
 
6 
2.1 
Agitation regained consciousness ............................................................................... 6 
2.1.1 
Definition of Conscious Recovery Agitation ....................................................... 6 
2.1.2 
Mechanism of Agitation Recovered Consciousness ............................................ 7 
2.1.3 
Risk Factors Agitation Recovery ......................................................................... 8 

 
 
 
 
2.1.4 
Agitation Assessment regained consciousness .................................................. 12 
2.1.5 
Agitation Prevention Strategy to Recover Consciousness ................................. 15 
2.2 
Pharmacology of Dexmedetomidine ......................................................................... 18 
2.2.1 
Pharmacokinetics Dexmedetomidine................................................................. 18 
2.2.2 
Pharmacodynamics of Dexmedetomidine ......................................................... 19 
2.2.3 
Drug Interactions ............................................................................................... 22 
2.2.4 
Contraindications ............................................................................................... 22 
2.3 
Pharmacology of Magnesium Sulfate ....................................................................... 23 
2.3.1 
Pharmacokinetics of Magnesium Sulfate........................................................... 23 
2.3.2 
Pharmacodynamics of Magnesium Sulfate ........................................................ 25 
2.3.3 
Dosage and Drug Interactions ............................................................................ 27 
2.3.4 Contraindications ...................................................................................................... 30 
2.4 
Theoretical Framework ............................................................................................. 31 
2.5 
Concept Framework .................................................................................................. 32 
CHAPTER 3RESEARCH 
METHODS
 
33 
3.1 
Research Design ........................................................................................................ 33 
3.2 
Place and Time of Research ...................................................................................... 33 
3.3 
Population and Research Sample .............................................................................. 33 
3.4 
Inclusion and Exclusion Criteria ............................................................................... 34 
3.4.1 
Inclusion Criteria ............................................................................................... 34 
3.4.2 
Exclusion Criteria .............................................................................................. 34 
3.4.3 
Production Criteria ............................................................................................. 34 
3.5 
Large Sample............................................................................................................. 34 
3.6 
Tools and Workpieces ............................................................................................... 35 
3.7 
Research Flow ........................................................................................................... 37 
3.8 
Research Procedure ................................................................................................... 38 

 
 
 
 
3.9 
Perioperative Disorder Management Protocol .......................................................... 42 
3.9.1 Intraoperative Hemodynamic Disorders Protocol ..................................................... 42 
3.9.2 Recovery of Consciousness Agitation Protocol ........................................................ 45 
3.10 Operational Definition............................................................................................... 45 
3.10.1 Variable Operational Definition ................................................................................ 46 
3.10.2 Operational Definition of Term................................................................................. 54 
3.11 Data Analysis Plan .................................................................................................... 57 
3.12 Research Ethics and Consent .................................................................................... 57 
3.13 Research Timeline ..................................................................................................... 59 

 
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TABLE LIST 
 
Table 2.1 Riker sedation-agitation scale (SSAR) ................................................. 13 
Table 2.2. Richmond agitation-sedation scale (SASR) ......................................... 14 
Table 2.3. Aono's four-point scale ........................................................................ 15 
Table 3.1. Research Timeline................................................................................ 59 
 

 
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IMAGE LIST 
Figure 2.1 Chemical group of dexmedetomidine .................................................. 18 
Figure 2.2. Effects of Dexmedetomidine .............................................................. 20 
Figure 2.3. Excretion of magnesium ..................................................................... 25 
Figure 2.4. Magnesium Site and Mechanism of Action ....................................... 26 
Figure 2.5 Theoretical Framework ........................................................................ 31 
Figure 2.6 Concept Framework ............................................................................ 32 
Figure 3.1. Instructions on How to Compound Research Drugs .......................... 39 

 
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LIST OF ATTACHMENTS 
 
Appendix 1. Research Explanation Sheet ............................................................. 69 
Appendix 2. Research Participation Consent Sheet .............................................. 73 
Appendix 3. Research Sheet ................................................................................. 81 
Appendix 4. Dummy Table ................................................................................... 85 
Appendix 5. Research Organizations .................................................................... 91 
Appendix 6. Research Fee Details ........................................................................ 92 

 
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ABBREVIATION LIST 
 
 
AV 
Atrioventricular 
EC50 
Half maximum effective concentration 
etCO2 
End-tidal carbon dioxide 
ECG 
Electrocardiography 
IM 
Intramuscular 
IV 
Intravenously 
IL-1 
Interleukin-1 
IL-6 
Interleukin-6 
LMA 
Laryngeal mask airway 
MRI 
Magnetic Resonance Imaging 
MAC 
Minimum alveolar concentration 
MgSO4 
Magnesium sulfate 
DRUGS 
Narcotics, psychotropics, and other addictive substances 
NMDA 
N-methyl-D-aspartate 
NaCl 
Sodium chloride 
PACU 
Post-anesthesia care unit  
DPO 
Postoperative delirium 
SASR 
Richmond Sedation Agitation Scale 
SSAR 
Agitation Sedation Scale Riker  
SPSS 
Statistical Package for Social Sciences 
TIVA 
Total Intravenous Anesthesia 
TNF-α 
Tumor necrosis factor alpha 

 
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BAB 1 
 
INTRODUCTION 
 
1.1 
Background 
Conscious recovery agitation is a state that includes restless states, disorientation, 
excitation, aimless movements, inability to calm down, throwing tantrums, and 
confusion during initial recovery from general anesthesia. The incidence of 
conscious recuperation agitation varied from 0.25% to 90.5%. Some of the factors 
influencing incidence are age, assessment tools used, definition, anesthesia 
techniques, type of surgery, and assessment time of conscious recovery agitation 
during recovery.1 The clinical consequences of conscious recovery agitation also 
vary. It is generally short-lived and resolves on its own, and the clinical 
consequences are often considered minimal. However, conscious recovery agitation 
can have significant clinical consequences, such as injury in patients suffering from 
conscious recovery agitation or injury to medical staff, falling out of bed, bleeding 
at the surgical site, detachment of an intravenous tube or catheter, accidental 
extubation, respiratory depression, and increased medical care costs.2,3 
Agitation during recovery from general anesthesia is a potentially serious 
phenomenon that has not been as well studied in the adult population as it is in the 
pediatric population. In the adult population, the incidence rate can reach 21.3% to 
45.9% globally and the number varies depending on several factors, one of which 
is the type of surgery. In patients with otorhinolaryngology surgery the incidence 
ranged from 22.2% in one study in Korea to 55.4% in one study in China, in elective 
craniotomy based on the study in China the incidence was up to 29%, and in cardiac 
surgery up to 48% in one study in Australia.4–7 Agitation of conscious recovery in 
adult patients has also been studied in 1 study in Tasikmalaya, Indonesia which 
showed agitation of conscious recovery in outpatient surgical patients, with a 
cumulative amount of 25.5% with 14.9% caused by desflurane and 10.6% caused 
by sevoflurane.8 Recognized risk factors that may trigger recovering agitation in 
adults include otorhinolaryngology, obesity, premediation with benzodiazepines, 
sevofluran anesthesia, endotracheal tubes, and a history of psychological illness.2,9  

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Dexmedetomidine, which is a highly selective α2-symtolytic, is an effective 
preventative agent of conscious recovery agitation. Several doses of 
dexmedetomidine have been studied and the results vary regarding the prevention 
of cough, postoperative pain, bradycardy, and hypotension but from the set of doses 
given they are equally beneficial in reducing the incidence of recovering 
agitation.10–13 Dexmedetomidine has also been shown to be superior to propofol in 
terms of the prevention of recovering agitation and has a minimal risk of respiratory 
depression than fentanyl, so Dexmedetomidine is the best standard for recovering 
agitation.14–16 This is the case with magnesium sulfate. Several published studies 
have shown that magnesium sulfate can improve postoperative analgesia, sedation, 
reduce postoperative agitation, and provide a good recovery after general anesthesia. 
In addition, magnesium sulfate in MgSO preparations4 20% has a more affordable 
price than dexmedetomidine. The availability of magnesium sulfate in Indonesia is 
also better and widespread because it is a national formulary drug. So magnesium 
sulfate is more cost effective when proven to be no more inferior in its effect in 
preventing agitation from recovering consciously. 1 
Based on this, the researcher is interested in researching the effectiveness of 
intravenous magnesium sulfate administration compared to intravenous 
dexmedetomidine to reduce conscious recovery agitation in patients at risk of 
recovering agitation, namely patients undergoing otorhinolaryngology surgery. 
 
1.2 
Problem Formulation 
Conscious recovery agitation does not only occur in pediatric patients. Young adult 
patients aged <40 years and older adults who undergo general anesthesia also have 
a risk of recovering agitation, although the number is not as high as in pediatrics. 
This opportunity is magnified by the type of patient surgery along with other risk 
factors. Surgery that manipulates the head and neck area increases the risk of 
recovering agitation, one of which is surgery in otorhinolaryngology. The incidence 
of conscious recovery agitation that occurs in this patient can reach 1 in 5 patients 
who have surgery. When considering the incidence rate and the number of patients 

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carried out at RSCM, it can be said that the topic of conscious recovery agitation 
needs to be raised in adult patients. 
There is no standard procedure for the prevention of conscious agitation at RSCM. 
Drugs commonly used in pediatric patients, such as propofol, do not have a 
meaningful effect in adult patients. In adult patients, according to the literature 
reference, it can be said that dexmedetomidine is the best standard for the 
prevention of agitation to recover consciousness. Although the effect of preventing 
agitation of conscious recovery is not superior to fentanyl, the side effects of 
respiratory depression are more common with fentanyl. Another therapeutic 
alternative is the use of magnesium sulfate as an anesthetic adjuvant. Its work as a 
sedative, analgesic, and neuroprotective agent is believed to be the main mechanism 
of magnesium to prevent agitation from regaining consciousness. However, there 
have not been many studies that compare the effectiveness of magnesium sulfate 
compared to the best standard for preventing agitation of regaining consciousness, 
namely dexmedetomidine, especially in the adult population in Indonesia.  
 
1.3 
Research Questions 
Does the use of magnesium sulfate as an anesthetic adjuvant have a similar effect 
of preventing agitation of conscious recovery than dexmedetomidine in patients 
undergoing otorhinolaryngological surgery? 
 
1.4 
Research Hypothesis 
The effectiveness of administering magnesium sulfate as an anesthetic adjuvant is 
no less good than Dexmedetomidine in the prevention of agitation of conscious 
recovery.  
 

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1.5 
Research Objectives  
1.5.1 General Purpose 
Comparing the effectiveness of magnesium sulfate administration with 
dexmedetomidine on the incidence of conscious recovery agitation in patients 
undergoing otorhinolaryngology surgery. 
1.5.2 Special Purpose 
- 
Comparing the proportion of events of agitation recovering conscious in 
otorhinolaryngology 
surgical 
patients 
between 
patients 
receiving 
intravenous magnesium sulfate with intravenous dexmedetomidine  
- 
To compare the amount of dosing of propofol as a heavy conscious 
recovering agitation rescue agent in patients receiving magnesium sulfate 
versus patients receiving propofol to determine the effectiveness of both 
agents 
in 
reducing 
the 
severity 
of 
recovering 
agitation 
in 
otorhinolaryngology surgery 
- 
To know and compare the onset and duration of events of conscious 
recovery agitation in patients receiving magnesium sulfate with patients 
receiving dexmedetomidine in otorhinolaryngology surgery 
- 
To compare changes in mean arterial pressure and pulse frequency in 
otorhinolaryngology surgery patients receiving intravenous magnesium 
sulfate with intravenous dexmedetomidine to find out how much the two 
agents have an impact on mean arterial pressure and pulse frequency 
- 
Comparing the amount of administration of ephedrine as a significant 
salvage agent of hypotension and bradycardia in patients receiving 
magnesium sulfate with dexmedetomidine in otorhinolaryngology surgery 
- 
Comparing the number of doses of fentanyl and the concentration of 
intraoperative sevoflurane used in patients receiving magnesium sulfate 
with dexmedetomidine in otorhinolaryngology surgery 
- 
Comparing the 1-hour postoperative pain score of patients receiving 
magnesium sulfate versus patients receiving dexmedetomidine in 
otorhinolaryngology surgery 

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- 
To determine and compare the duration of extubation in patients receiving 
magnesium sulfate versus patients receiving dexmedetomidine in 
otorhinolaryngology surgery 
 
1.6 
Research Benefits 
1.6.1 Scientific Benefits 
1. This study can be used as a reference for new research that will be conducted 
on the use of magnesium sulfate in the prevention of conscious agitation 
when compared to other agents or in special populations. 
2. Educational institutions can implement the use of magnesium sulfate to 
prevent agitation from regaining consciousness. 
3. Researchers can increase knowledge about the effectiveness of magnesium 
sulfate in reducing the incidence of agitation and recovering consciousness 
1.6.2 Clinical Benefits 
1. This study could be the basis for magnesium sulfate to be routinely practiced 
in otorhinolaryngology surgery as an alternative to dexmedetomidine, 
especially in patients with a high risk of agitation regaining consciousness. 
2. Patients complete the procedure in a more comfortable state because they 
are less restless and postoperative pain is reduced 
3. This research can be used as a reference to make guidelines for the practice 
of preventing agitation from recovering consciousness  
1.6.3 Benefits of Community Service 
1. The results of this study are expected to contribute to reducing the 
morbidity rate of patients caused by conscious recovery agitation 
2. This result has the potential to reduce the burden of hospital costs due to 
the severe side effects posed by the heavy conscious recovery agitation

 
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BAB 2 
 
LITERATURE REVIEW 
 
2.1 
Agitation regained consciousness 
2.1.1 Definition of Conscious Recovery Agitation 
Conscious recovery agitation is a phenomenon that occurs after general anesthesia, 
this process is characterized by a state of psychomotor excitation that is temporary 
and varies between individuals. Common symptoms include aimless movements, 
restlessness, and confusion. This process usually lasts for a short time, ranging from 
2 to 5 minutes after the discontinuation of the inhaled anesthetic agent and lasting 
up to 15 minutes after extubation.9 However, some cases can last up to 30-45 
minutes after extubation.17,18 During this agitation phase, the patient is often 
unresponsive to communication and has difficulty following verbal commands. 2,9  
It is important to distinguish between conscious recovery agitation and other types 
of perioperative delirium, such as delirium in the post-anesthesia care unit (PACU) 
or postoperative delirium (DPO). Conscious relapse agitation occurs when the 
patient transitions back to consciousness, whereas delirium is a reversible change 
in consciousness, with attention disorders and cognitive deficits. The incidents are 
also related to each other. In a prospective cohort study in China, geriatric patients 
reported that the incidence of delirium recovered, consciously increased the 
incidence of DPO. Despite the differences, some literature states that agitation 
regains consciousness and DPO in general are often considered similar in medical 
practice.2,9,19–22 
In addition to the agitation of recovering consciousness in some literature, it is also 
known that there is a term delirium of recovering consciousness. Delirium 
recovering consciousness is a state of acute confusion that occurs during recovery 
from anesthesia. Patients with recovering delirium may experience disorientation, 
hallucinations, restlessness, and aimless hyperactive physical behavior just like 
recovering agitation, but some literature says recovering delirium is not equivalent 
to recovering agitation. Conscious recovered delirium can include hypoactive signs 
or mixed forms, without triggering agitation. However, the terminology of 

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conscious recovered agitation and conscious recovered delirium were used 
interchangeably in some studies. This is because the measuring instruments used in 
conscious recovery agitation and conscious recovery delirium are the same, for 
example the Riker sedation-agitation scale or the Richmond agitation-sedation 
scale.9,19 
2.1.2 Mechanism of Agitation Recovered Consciousness 
The etiology of conscious recuperation agitation is not yet fully understood.  
Increased postoperative pain sensation has been suspected as the cause. However, 
pain is not the only major cause because conscious recovery agitation can occur in 
patients undergoing MRI (Magnetic Resonance Imaging). There are triggers and 
there are those that increase the risk of recovering agitation which is multifactorial 
in nature.2 
Inhalation anesthesia plays an important role in the occurrence of agitation and 
regaining consciousness. Inhaled anesthesia such as sevoflurane, isoflurane, and 
desflurane are suspected, especially in pediatric populations, to alter brain activity 
and disrupt the balance between excitation and synaptic inhibition of central 
nervous system neurons. In the adult population, the main conjecture is that during 
the excitation stage or "phase 2" of anesthesia recovery, hyperarousal appears in 
response to internal and external stimuli while consciousness is restored. For 
example, in surgery involving the oral cavity, the sensation of shortness of breath 
due to the placement of the casing in the oral cavity may contribute to the frequent 
occurrence of conscious recovery agitation in this group.2,9 
Uninhibited sympathetic activation due to poorly handled nociception stimuli or the 
presence of an attached endotracheal catheter and tube can also trigger resuscitation 
agitation. Other studies have shown that conscious recovery agitation is more 
common in patients with higher inflammatory mediators (interleukin-6 [IL-6], 
tumor necrosis factor alpha [TNF-α], and T and B lymphocytes) as well as 
postoperative endogenous catecholamines, which indicate a neuroinflammatory 
contribution.2,23 

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The solubility of anesthesia gases affects the incidence of agitation to recover 
consciousness. Low-solubility inhalation agents will cause different levels of 
recovery in brain function due to differences in inhalation anesthesia clearance from 
the central nervous system. This results in hearing and movement being restored 
first, before cognitive function returns which leads to the agitation of regaining 
consciousness. In addition, increased concentrations of lactate and glucose in the 
parietal cortex due to sevoflurane anesthesia, and the occurrence of clinically 
unseen epileptogenic activity of sevoflurane have been proposed as triggers for 
recovering conscious agitation.9 
2.1.3 Risk Factors Agitation Recovery 
Identifying the causes and risk factors of conscious recovery agitation is important. 
As a clinician, risk factors need to be detected and addressed to reduce incidence 
and prevent adverse consequences. In recovering agitation, there are several 
differences in risk factors for the pediatric and adult populations.9  
Broadly speaking, risk factors for agitation of conscious recovery in children are 
preschool age (2–5 years), no previous history of surgery, no previous 
hospitalization or intervention, poor adaptability, attention deficit disorder and 
hyperactivity, daily patient behavior, low psychological maturity, preoperative 
anxiety, parental anxiety, patient and parent interaction with medical personnel,  
lack of premediation (with midazolam), paradoxical reactions to midazolam 
recorded in the child's medical history, type of surgery, use of inhaled anesthesia 
with a low blood–gas partition coefficient (e.g., sevoflurane and desflurane), too 
rapid recovery (forcibly awakened), and postoperative pain.9,19,20,24–26  
In the adult population, conscious recovery agitation is influenced by several risk 
factors including age, sex, obesity (body mass index ≥ 30 kg/m2), African ethnicity, 
number of intubation attempts, type of surgery, emergency surgery, anesthesia 
method (inhalation anesthesia), duration of surgery or anesthesia, pre-existing 
mental health problems (e.g., psychiatric problems or cognitive impairment), 
chronic lung disease,  recent smoking, alcohol intoxication, acute withdrawal 
syndrome from drug abuse (narcotics, psychotropics, and other addictive 
substances), anticholinergics, doxapram, premediation with benzodiazepines, 

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repeated intubation attempts, urgency incontinence, postoperative pain, 
postoperative nausea and vomiting, and the presence of invasive instruments in the 
patient's body (e.g., urinary catheters, chest tubes, or tracheal tubes). 9,19,20,24,25,27 
A. Age 
Young adult patients (<40 years) and geriatric patients (>64 years) had a higher 
incidence of recovering agitation or recovering delirium compared to middle-
aged surgical patients. One of the causes geriatrics to have a higher incidence 
is hearing impairment which can increase the incidence of agitation to recover 
consciousness by up to 2.3 times. In addition, children have a higher risk of 
experiencing recovering agitation. In pediatric patients, younger age is 
associated with an increased risk of preoperative anxiety that can increase the 
incidence of recovering agitation. Age-related physiological changes may 
increase the sensitivity and toxicity of the drug in patients with advanced age 
compared to young adults. Complications caused by conscious recovery 
agitation can also have more serious consequences in elderly patients.4,9,22,28–31  
B. Gender 
In the child population, sex has nothing to do with the incidence of agitation. 
In contrast to the adult population, some studies have shown that male sex is 
associated with the incidence of agitation regaining consciousness. This may 
be due to lower pain tolerance in men after surgery. In addition, male sex is a 
risk factor for bladder discomfort associated with catheters and also smoking 
habits which are also closely related to the increased incidence of recovering 
agitation.4,30 
C. Types of Surgery 
The type of operation affects the incidence of recovering agitation. In children 
aged 3–7 years, ophthalmology and otorhinolaryngology procedures are related 
to the occurrence of recovering agitation. In particular, otorhinolaryngology 
procedures are an independent risk factor for conscious recovery agitation. 
Some also mention strabismus surgery and tonsillectomy identified as risk 
factors for agitation of conscious recovery in pediatric patients. In the adult 
population, spine surgery, musculoskeletal surgery, oral cavity surgery, 
otorhinolaryngology surgery, breast surgery, and abdominal surgery are 

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closely associated with an increased incidence of recovering agitation. The 
duration of the action also affects the incidence of recovering agitation. Longer 
duration of operation is associated with an increased incidence of recovering 
agitation. The use of chemicals during surgery also needs to be considered, 
there is one case report of alcohol use in the action of celiacus plexus block 
triggering agitation of conscious recovery in a 66-year-old geriatric patient. 
4,9,19,28,31,32 
D. Anesthesia Techniques 
It is still unclear whether intravenous anesthesia or inhalation has the same 
effect on the incidence of regaining consciousness. In both groups, children 
and adults, studies have shown mixed results. There are several studies that 
show no significant difference between inhaled and intravenous anesthesia on 
the incidence of recovering agitation. However, some show TIVA (Total 
Intravenous Anesthesia) has a lower incidence of conscious recovered agitation 
compared to inhalation.33 Premediation of benzodiazepines has been reported 
to increase the incidence of recovering agitation in the adult population. 
Inhaled anesthesia such as halothan, isofluran, desfluran, and sevofluran can 
all be triggers for recovering agitation. However, conscious recovery agitation 
is more common with inhaled anesthesia that has low blood-gas solubility, such 
as sevoflurane and desflurane. In low-blood-gas solubility inhalation agents, 
sevoflurane triggers conscious recovery agitation more often than desflurane. 
Inhalation agents that have the potential to reduce the rate of conscious 
recovery agitation in the pediatric population are nitrous oxide (N2O). 4,9,27,28,30 
In addition to inhalation anesthetic agents, anesthesia techniques also need to 
discuss the involvement of neuromuscular blocking agents and their reversals. 
Studies that discuss such agents are still few. One study showed rocuronium-
sugammadex reduced the incidence, severity, and duration of conscious 
recovery agitation in patients undergoing closed reduction of nasal fractures 
compared to succinylcholine. It is suspected that due to increased lactate and 
potassium concentrations, incomplete neuromuscular blockade during surgery, 
increased intraocular pressure, and histamine release due to succinylcholine 

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administration may cause greater negative effects on recovering agitation, 
compared to the use of rocuronium-sugammadex.9 
E. Pain 
Pain is a major risk factor for conscious recovery agitation in both children and 
adults, although conscious recovery agitation has been reported to occur even 
in painless procedures and can occur regardless of pain intensity. An increased 
risk of agitation recovering consciousness is common in patients with severe 
postoperative pain. In adults, an increased risk of agitation occurs when the 
postoperative numerical pain assessment scale scores ≥ 5 points.9,28,30  
F. Preoperative Anxiety  
Several studies have found a link between preoperative anxiety levels and 
recovering agitation. Patients with severe preoperative anxiety have an 
increased risk of agitation regaining consciousness. An observational study 
with soldiers from war zones undergoing surgery, showed that 50% of patients 
who experienced recovering agitation had a previous psychiatric diagnosis, 
such as anxiety, post-traumatic stress disorder, or depression. Not only war, 
stress disorders experienced in victims of natural disasters can also increase the 
incidence of agitation to recover consciously.28,31,34  
 
 

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2.1.4 Agitation Assessment regained consciousness 
The diagnosis of conscious recovery agitation in adults is a challenge for a clinician. 
This is because unlike in pediatric patients, there is no validated diagnostic test to 
establish conscious agitation. Most studies use the Riker Agitation Agitation Scale 
(SSAR) or the Richmond Sedation Agitation Scale (SASR) to diagnose conscious 
recovered agitation, but both tools were only validated in intensive care unit patients. 
The SASR value used as the definition of conscious recovery agitation varies in 
various studies, but it can be concluded that some use the SASR value > +1, SASR > 
+2, and SASR > +3. The validity and reliability of SASR have also been tested in 
Indonesia by Pradian et al. (2014) with the results of reliability and validity being 
better than the Ramsay scale.35 SASR measurement has also become the standard 
standard at Cipto Mangunkusumo Hospital (RSCM) based on the President 
Director's Regulation on RSCM Disorderly Disorder Service Guidelines. In this 
guideline, the patient is said to be hyperactive delirium when SASR ≥ 1.36 A third 
diagnostic tool, known as the Aono four-point scale, can also be used. The 
advantage of this scoring is that all of these scores provide clear observer criteria 
between scores to minimize subjectivity and do not require the addition of category 
components. The thing to remember about this test tool is that it is all an agitation 
measurement tool and does not assess cognitive impairment.1,2,9 
 
 

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Table 2.1 Riker sedation-agitation scale (SSAR) 
Score 
Categories 
Description 
7 
Dangerous 
agitation 
Trying to remove the monitor and device or trying to 
get out of bed; fidgeting with restlessness; assault 
staff. 
6 
Very restless 
Remains restless despite getting periodic verbally 
soothing words, biting the endotracheal tube, needing 
restrain. 
5 
Restless 
Anxious or restless; trying to move; be calm by 
providing guarantees or reinforcement. 
4 
Calm 
and 
cooperative 
Calm, easy to wake up, able to follow instructions. 
3 
Sedated 
It is difficult to wake up, respond to verbal cues or 
gentle vibrations, but then fall back asleep. 
2 
Highly sedated 
Unable to communicate, responding to physical 
stimuli but not verbal cues, may move spontaneously. 
1 
Unresponsive  
Unable to communicate, little or no response to 
painful stimuli. 
 
Source: Tolly B, Waly A, Peterson G, Erbes CR, Prielipp RC, Apostolidou I. 
Adult Emergence Agitation: A Veteran-Focused Narrative Review. Anesth Analg. 
2021; 132(2):353–64 
 

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Table 2.2. Richmond agitation-sedation scale (SASR) 
Score 
Categories 
Description 
+4 
Combative 
Overtly resisting, aggressive, a direct threat to staff. 
+3 
Very agitated 
Removing or removing the endotracheal tube or 
catheter; be aggressive. 
+2 
Agitated 
Aimless frequency movement, against the ventilator. 
+1 
restless 
Anxious but not aggressive or strong movements 
0 
Conscious and 
calm 
Spontaneous full contact 
-1 
Drowsy 
Not fully conscious, but can remain awake for a long 
time (opening eyes/eye contact) with a loud 
stimulation (>10 seconds). 
-2 
 Light sedation 
Drowsiness but waking up briefly with eye contact to 
sound (<10 seconds) 
-3 
Deep sedation 
There is no response to sound, but there is movement 
or eye opening in response to physical stimuli. 
-4 
Unarousable 
There is no response to sounds or physical stimuli. 
 
Source: Tolly B, Waly A, Peterson G, Erbes CR, Prielipp RC, Apostolidou I. 
Adult Emergence Agitation: A Veteran-Focused Narrative Review. Anesth Analg. 
2021; 132(2):353–64 
 

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Table 2.3. Aono's four-point scale 
Score 
Categories 
1 
Calm down 
2 
Not quiet, yet can be calmed down easily 
3 
Difficulty calming down, moderate agitation or agitation 
4 
Fighting, disorientation, hyperactivity 
 
Source: Tolly B, Waly A, Peterson G, Erbes CR, Prielipp RC, Apostolidou I. 
Adult Emergence Agitation: A Veteran-Focused Narrative Review. Anesth Analg. 
2021; 132(2):353–64 
 
2.1.5 Agitation Prevention Strategy to Recover Consciousness 
Prevention of agitation of conscious recovery can be done in pharmacological and 
non-pharmacological ways. Non-pharmacologically in adult patients, patients are 
educated about pain expectations and minimize the use of invasive devices attached 
to the patient. Pharmacologically, modifying anesthesia techniques and drug 
selection and the way they are administered can reduce agitation to recover 
consciously. In a randomized clinical trial, TIVA with propofol and remifentanil 
reduced the incidence of conscious recovering agitation compared to volatile 
induction and maintenance of anesthesia with sevofluran in children aged 2–6 years, 
after strabismus surgery. In adults, the effect of anesthesia techniques on the 
incidence of conscious recovery agitation showed mixed results. In a prospective 
study with 1,359 patients and a retrospective study with 488 patients, the incidence 
of conscious recovery agitation was no different from the anesthesia techniques 
used. Another study showed that conscious recovery agitation was less common 
with TIVA compared to inhalation anesthesia in a prospective observational study 
with 2,000 patients, and a retrospective study with 792 patients. In a randomized 
clinical trial in 80 patients undergoing nasal surgery, conscious recovery agitation 

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was reduced in incidence with TIVA compared to inhalation. In another 
randomized clinical study in 90 patients, it was found that TIVA can shorten the 
duration of conscious recovery agitation experienced by patients. Thus, it can be 
said that the use of TIVA anesthesia techniques can be considered if patients are 
estimated to be at high risk of agitation to recover consciousness.9,25,33,37 
Propofol is the drug of choice for the prevention and treatment of conscious 
recovery agitation in pediatric patients. In a meta-analysis in pediatric patients, 
propofol showed a prophylactic effect on recovering agitation, depending on the 
time of administration. Continuous infusion of propofol during maintenance of 
anesthesia, or the addition of a propofol bolus at the end of surgery, showed a 
preventive effect against conscious recovery agitation in pediatric patients 
undergoing general anesthesia. However, there have not been enough studies that 
discuss the effect of a single dose of bolus propofol at the end of surgery on agitation 
of regaining consciousness in adult patients.38 
Prophylactic administration of μ-opioid agonists (such as fentanyl, sufentanil, 
alfentanil, or remifentanil) has been shown to reduce the incidence of agitation of 
regaining consciousness after anesthesia with sevoflurane in a metaanalysis of the 
pediatric population. The effects of opioids on agitation of conscious recovery in 
adult patients have not been widely evaluated. Several studies have shown that 
administering opioids during recovery can reduce the occurrence of recovering 
agitation, but result in delays in regaining consciousness in patients.9 
Another therapy that can reduce agitation to recover consciousness is the 
administration of Ketamine. Ketamine is a noncompetitive N-methyl-D-aspartate 
(NMDA) receptor antagonist, which has sedative, amnestic, and analgesic 
properties. Administration of ketamine (0.25 mg/kg and 0.5 mg/kg) 10 minutes 
before the end of surgery contributed to the prevention of agitation, recovering 
consciousness without delayed recovery in children after sevofluran anesthesia. 
Other drugs that can be given to prevent agitation recover from consciousness are 
magnesium sulfate and alpha 2 agonists such as dexmedetomidine.9 
Dexmedetomidine acts on α2-adrenoreceptor receptors as an agonist agent. Its 
sedative and analgetic effects work to suppress the incidence of agitation to recover 

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consciousness. The effective dosage of dexmedetomidine has been extensively 
researched in several studies. There was a double-blinded randomized controlled 
trial that examined 3 different doses in adult patients, namely 0.25, 0.5, and 1 
mcg/kg. In the study, it was shown that the dose was significantly as good in 
reducing agitation to recover consciousness, but the effect of cough suppression 
was superior when using a dose of 1 mcg/kg.39 Studies in other pediatric populations 
showed that a dose of 0.5 mcg/kg compared to 1 mcg/kg was equally effective in 
reducing the incidence of resuscitation agitation, but a dose of 0.5 mcg/kg had a 
shorter duration of extubation, wakefulness, and post-anesthesia treatment duration 
than 1 mcg/kg.12 In geriatric patients over 70 years of age, the required dose of 
dexmedetomidine infusion is even lower. In this population, ED50 prevention of 
conscious recovery agitation was achieved at a dose of 0.3 mcg/kg/hour while ED95 
was predicted to be 0.42 mcg/kg/hour.40 The timing of administration of 
dexmedetomidine for the prevention of conscious recovery agitation is still not 
standard, but there is 1 study that shows that giving dexmedetomidine at the end of 
the action is better at preventing conscious recovery agitation compared to giving 
it at the beginning of the action. In 1 metaanalysis, it was stated that in addition to 
agitation of regaining consciousness, other problems such as cough, nausea and 
vomiting, chills, and pain can be prevented also by dexmedetomidine with the 
disadvantage of prolonging the extubation time but the length of duration is not 
clinically significant, with an estimated 1-8 minutes and an average time of 2 
minutes. 41,42 
Magnesium sulfate is one of the agents that can prevent agitation from recovering 
consciously.43 As an NMDA antagonistic agent, magnesium sulfate can act as a 
sedative and analgesic agent.  In studies in adult patients undergoing mastectomy 
and in pediatric patients undergoing ophthalmology surgery, administration of 
magnesium sulfate 10% bolus 30 mg/kg followed by an infusion of 10 mg/kg/h was 
effective in reducing the incidence of regaining consciousness. In urological and 
abdominal surgery, magnesium sulfate can reduce discomfort due to the insertion 
of a urinary catheter. Until now, there is no standard dose used.44–46  

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2.2 
Pharmacology of Dexmedetomidine 
Dexmedetomidine, or 4-[(1S)-1-(2,3-dimethylphenylethyl]-1H-imidazole, with the 
chemical group C13H16N2 is a S-enantiomer dextrorotation of medetomidine, a 
kind of agent used in veterinary medicine. α2-adrenoreceptor receptor agonist 
agents (clonidine and dexmedetomidine) have sympatholytic, analgesic, and 
sedative properties. Several studies have shown that α2 agonists can reduce the 
incidence of agitation, recover consciously, and are much superior compared to 
midazolam to reduce the incidence. In pediatric patient studies, Dexmedetomidine 
was found to reduce the incidence of conscious recovery agitation compared to 
placebo. Moreover, it is said that its effect to reduce agitation of conscious recovery 
is superior compared to propofol, midazolam, fentanyl, and sufentanil.1,2,9,47  
 
Figure 2.1 Chemical group dexmedetomidine 
Source: Kaur M, Singh P. Current role of dexmedetomidine in clinical anesthesia 
and intensive care. Anesth Essays Res. 2011; 5(2):128 
2.2.1 Pharmacokinetics Dexmedetomidine 
Dexmedetomidine currently has only authorized use via intravenous (IV) infusion, 
but a variety of other methods of administration beyond the LEBL have been 
studied. Extravascular use of dexmedetomidine allows the avoidance of the drastic 
increase in plasma levels that is common after IV administration. When 
administered orally, a significant first cross-section phenomenon occurs, with a 
bioavailability rate of only 16%. If administered through IV, dexmedetomidine has 
a rapid distribution phase, with a distribution half-life of six minutes and a final 

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elimination half-life of about two hours. The drug exhibits linear kinetics at doses 
between 0.2 - 0.7 micrograms (mcg)/kg/hour through IV infusions lasting up to 24 
hours. In the tune, the dispensing volume of dexmedetomidine is about 118 liters. 
Dexmedetomidine has a high affinity for plasma proteins, with 94% of the drug 
bound to albumin and α1-glycoproteins. After distribution, dexmedetomidine is 
metabolized in the liver with an extraction ratio of 0.7. The context-sensitive half-
life of dexmedetomidine varies, ranging from 4 minutes after infusion for 10 
minutes to 250 minutes after infusion for 8 hours.47–49 
Dexmedetomidine undergoes a biotransformation process in the liver. This process 
involves N-glucuronidation directly by the uridine enzyme 50-diphospho-
glucuronosiltransferase (UGT2B10, UGT1A4), which is responsible for 
approximately 34% of dexmedetomidine metabolism. In addition, within liver 
microsomes, dexmedetomidine undergoes hydroxylation triggered by the 
cytochrome P450 (CYP) enzyme, specifically CYP2A6. These two metabolic 
processes produce metabolites that are then excreted from the body, the majority 
through urine (about 95%) and the rest through feces (4%). In patients with 
impaired liver function, it is necessary to make dose adjustments due to the lower 
metabolic rate.47–49 
2.2.2 Pharmacodynamics of Dexmedetomidine 
Dexmedetomidine is a beneficial sedative agent with analgesic properties, 
maintaining hemodynamic stability, and the ability to restore respiratory function 
in patients who are receiving mechanical ventilation due to its non-depressive 
effects on breathing. The effects of sedation, anxiolysis, and analgesia are triggered 
depending on the dosage of the drug administered. Working on α2-adrenoreceptors, 
dexmedetomidine is a highly selective α2-adrenoreceptor agonist (α2:α1 ratio of 
1620:1 vs. 220:1) with a 7 to 8 times higher affinity to α2-adrenoreceptors 
compared to clonidine. The effect of its work is caused when it is bonded to the G-
Protein-coupled α2-adrenrereceptor agonists subtypes α2A, α2B, and α2C each of 
which provide different physiological effects.47–49 
 
 

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Source: Kaur M, Singh P. Current role of dexmedetomidine in clinical anesthesia 
and intensive care. Anesth Essays Res. 2011; 5(2):128 
The sedative and hypnotic effects of dexmedetomidine are believed to occur 
through activation of α2-receptor presynapses and postsynapses at the locus 
coeruleus. Dexmedetomidine is also known to affect natural pathways in the body 
that support sleep. The sedative effect of dexmedetomidine depends on the 
concentration of the drug in the plasma. Plasma concentrations between 0.2 to 0.3 
ng/mL produce significant sedation but still allow a person to be awakened. Deep 
and unawakening sedation is believed to occur at plasma concentrations above 1.9 
ng/mL. The use of perioperative dexmedetomidine may reduce the dose of 
sevoflurane administered. In randomized studies of hyposcopy patients, it was 
found that doses of dexmedetomidine of 0.6, 0.8, and 1 mcg/kg reduced the MAC 
of sevoflurane by 38%, 48%, and 51%. In studies of patients with obesity, 
dexmedetomidine may reduce the MAC of sevoflurane by up to 40%.2,9,47,50,51 
The analgesic effects of α2-agonists are believed to be mediated by binding to α2-
receptors in the center and α2 receptors in the spinal cord. Pain transmission is 
suppressed through hyperpolarization of interneurons and reduced release of 
pronociceptive transmitters such as P substances and glutamate. Nonetheless, 
Dexmedetomidine in concentrations up to 1.23 ng/mL does not provide adequate 
analgesia to heat or electrical stimuli. In a crossover trial comparing the respiratory 
and analgesic effects of dexmedetomidine and remifentanil, plasma concentrations 
Figure 2.2. Effects of Dexmedetomidine 

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of dexmedetomidine up to 2.4 ng/mL provided less effective analgesia compared to 
remifentanil.9,47 
Dexmedetomidine produces a distinctive biphasic hemodynamic response, 
resulting in hypotension at low plasma concentrations and hypertension at higher 
plasma concentrations. It is thought to be derived from the activation of α2B 
receptors in vascular smooth muscles, which causes peripheral vasoconstriction 
thus causing hypertension. This process is accompanied by a rapid decrease in heart 
rate, which is caused by the baroreceptor reflex. After a few minutes, when the 
plasma concentration of dexmedetomidine decreases, vasoconstriction is weakened, 
as dexmedetomidine also activates α2 receptors in vascular endothelial cells, 
resulting in vasodilation. Together with presynaptic α2-adrenrereceptors that inhibit 
the release of sympathetic catecholamines, and increased vagal activity, this results 
in a hypotension phase. These hypotension and lowering pulse rate effects are 
beneficial for reducing intubation response, reducing intraoperative bleeding and 
creating a clearer field of operation for operators.47,52–54 
The mechanism by which dexmedetomidine acts on peripheral α2-adrenoceptor 
receptors, makes dexmedetomidine also have decongestant and antisialagogue 
effects. Theoretically, it may reduce intestinal motility, although to the best of our 
knowledge, there have been no reports of associated complications. 
Dexmedetomidine suppresses the shivering process, possibly due to α2B receptor 
agonism in the hypothalamus. It provides a diuretic effect by inhibiting the action 
of antidiuretic hormones in the collective ducts.48,55 
Dexmedetomidine is highly effective at preventing agitation from recovering 
consciousness in a multimodal manner. Activation of α2-adrenergic receptors by 
Dexmedetomidine produces sedative and hypnotic effects through increased 
activity of inhibitor neurons in the locus coeruleus of the brainstem, anxiolytic by 
reducing the release of stress hormones such as norepinephrine, and analgesics by 
reducing the release of substance P in the dorsalis cornea of the spinal cord. Some 
of these key mechanisms, especially their analgesic properties, make 
dexmedetomidine 
superior 
for 
preventing 
agitation 
from 
regaining 
consciousness.56–58  

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2.2.3 Drug Interactions 
Dexmedetomidine reduces the need for other anesthesia such as isoflurane, 
sevoflurane, propofol, thiopental, and fentanyl. Observations made in abdominal 
surgery found that the required amount of sevoflurane was less when administered 
concomitantly with dexmedetomidine (Loading Twelve 1 μg/kg and maintenance 
dose 0.5 μg/kg/hour). In addition, the half-maximum effective concentration (EC50) 
Sevoflurane to be 21% lower for insertion Laryngeal Mask Airway (AML) in 
pediatric patients when premediation with dexmedetomidine 2 μg/kg was 
administered intranasal For propofol, there are studies that show EC values50 
propofol for successful LMA insertion without relaxants was 3.18 μg/mL in the 
group receiving dexmedetomidine pre-anesthesia 1 μg/kg, compared with 6.75 
μg/mL in the group receiving placebo saline.52,59 
Dexmedetomidine 
can 
also 
be 
used 
for 
opioid-saving 
anesthesia. 
Dexmedetomidine is useful for reducing the effects of respiratory depression and 
nausea triggered by opioid administration. In patients who have been anesthetized, 
the administration of analgesics such as opioids is often given when heart rate and 
blood pressure rise. The lowering hemodynamic effects of dexmedetomidine may 
mask pain assessment and as a result lower intraoperative opioid consumption.47,52 
The interaction between dexmedetomidine and antihypertensive agents has been 
investigated. Beta-blockers may cause increased effects of hypotension and 
bradycardia. Calcium channel blockers may relieve changes in heart rate and blood 
pressure 
associated 
with 
dexmedetomidine 
infusion 
without 
affecting 
catecholamine levels in plasma.16  
2.2.4 Contraindications 
Uncontrolled hypotension and second- or third-degree heart block (unless with a 
pacemaker) can potentially worsen as a result of dexmedetomidine. Comorbid acute 
cerebrovascular conditions are also considered contraindications because animal 
studies have shown decreased blood flow to the brain with dexmedetomidine. 
However, studies in humans have shown the maintenance of flow-metabolism 
linkage with decreased metabolic consumption levels in the brain that are in line 
with decreased cerebral blood flow.48 

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2.3 
Pharmacology of Magnesium Sulfate 
Magnesium (Mg++) is a divalent cation with a molecular weight of 24,303 u, the 
fourth most abundant cation in the body and the second at the intracellular level. 
Magnesium accounts for about 0.03% of the total body weight, 95% is filtered in 
the glomerulars and 5% is excreted through feces. Magnesium is concentrated 
mainly in bones (60%), muscles (20%), and soft tissues (20%). The Quarter Mg 
present in muscles and bones can be exchanged. Only 1% of the total is extracellular 
magnesium. There are three fractions of magnesium in serum: ionized (active form), 
bound to proteins, and contained in complex anions (phosphate and citrate). In 
adults, daily consumption is recommended as much as 250-350 mg (10.4-14.6 
mmol) and plus 100-150 mg for pregnant women and pediatricians.60,61  
Magnesium serves as a coenzyme for various biological processes, including 
protein synthesis, neuromuscular function, and nucleic acid stability. Magnesium is 
an intrinsic component of many adenosine 5-triphosphatase and an endogenous 
regulator of some electrolytes.  As a noncompetitive inhibitor of calcium channels 
regulated by inositol triphosphate, magnesium functions as an endogenous calcium 
antagonist by influencing its absorption and distribution. Magnesium also exhibits 
a modulating effect on sodium and potassium currents, thus affecting the membrane 
potential. Magnesium also has a depressant effect on the intestinal nervous system 
because it functions as an antagonist of the N-methyl-D-aspartate (NMDA) 
glutamate receptor and an inhibitor of catecholamine release.60–63 
2.3.1 Pharmacokinetics of Magnesium Sulfate 
Magnesium sulfate has the chemical name magnesium sulfate heptahydrate 
(MgSO4.7H2O). The maintenance of magnesium homeostasis is largely regulated 
by intestinal absorption and renal excretion. Magnesium ions are absorbed by the 
small intestine, especially when administered orally. Magnesium is absorbed in the 
small intestine through two different pathways that depend on the dosage and 
dietary intake formula. Magnesium is absorbed via active transcellular transport at 
low intraluminal concentrations, but at high concentrations magnesium is absorbed 
through passive diffusion. When magnesium levels are normal, about 40-50% of 
the magnesium consumed can be absorbed. The absorption of magnesium appears 
to be somewhat inhibited by fiber, phytic, and oxalic acid through the formation of 

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complexes that are difficult to decompose. The binding of magnesium with anions 
(phosphates) or fatty acids also reduces the amount of magnesium absorbed. As the 
amount of magnesium consumed increases, the fraction of magnesium absorbed 
also decreases. A decrease in magnesium levels can also occur due to two main 
factors, namely loss of magnesium through digestion and kidneys. Loss of 
magnesium through digestion can occur as a result of various conditions that cause 
diarrhea or disorders of the bile ducts. Loss of magnesium through the kidneys can 
occur as a result of various conditions, such as the use of diuretics, gentamacis, 
cisplatin, and cyclosporine. When magnesium is administered intravenously (IV), 
onset is rapid, with peak effects obtained within 10 minutes, and with a duration of 
30 minutes. For the intramuscular (IM) pathway, the onset is slower and only 
reaches the peak effect in 60 minutes with a half-life of 4 hours.61,63  
The largest distribution of magnesium is intracellular. As much as 99% of the total 
magnesium is in the intracellular space (53% to 60% is found in bone tissue, 20% 
to 27% in muscle tissue, and 19% in soft tissue) and 1% is in extracellular (60% 
ionized, 30% protein-bound, and 10% anion-complex). The magnesium elimination 
route, mostly through the kidneys (figure 3). Magnesium excretion averages about 
3-5 mmol/day, but can be reduced to 0.5 mmol/day when severely deficient in 
magnesium. About 80% of the magnesium flowing through the kidneys is 
ultrafiltrated and enters the tubules, but more than 95% is resorbed by small portions 
of the nephron. The most important part of this process takes place in the Henle 
ansa, the thick ascendant branch to be precise. In this part, about 70% of magnesium 
is reabsorbed passively, following the flow of sodium and chloride that are also 
reabsorbed. A special protein called claudin 16 plays an important role in this 
process. The loss of function of this protein due to genetic mutations can lead to a 
rare disorder in humans, in which magnesium is abundantly wasted through the 
urine.61,63,64 

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Figure 2.3. Excretion of magnesium 
Source: Warner DS, Herroeder S, Scho ME. Magnesium — Essentials for 
Anesthesiologists. 2011; (4) 
The regulation of magnesium transport has no specific endocrine control, although 
some hormones have been proposed to alter magnesium homeostasis. 
Parathormones and vitamin D stimulate magnesium reabsorption in the kidneys, 
specifically the henle anna and distal contortus tubules, and intestines. In addition 
to aiding in the absorption process of the kidneys and intestines, parathormones 
remove magnesium from the bones. While insulin can reduce the kidney's 
magnesium excretion and increase its absorption by cells.61 
2.3.2 Pharmacodynamics of Magnesium Sulfate 
Magnesium sulfate has several known mechanisms of action (Figure 4), namely the 
activation of the Na-K-ATPase pump which can be inhibited in the state of 
concentration of Mg2+ a high, competitive antagonist to calcium channels that 
provides the characteristics of blocking presynaptic acetylcholine release and 
increasing the potential threshold of postsynaptic action, blocking the release of 
catecholamines from the adrenal glands and adrenergic nerve endings, as well as 
reducing the release of cytokines (IL-1, IL-6, TNF-α, and substances P) and 
inhibition of platelet aggregation, non-competitive antagonists against R-NMDA, 
sinusoidal and atrioventricular (AV) blocks, PR prolongation, and QRS dilation.  
Each of these mechanisms is dose-dependent, which involves the risk of toxicity at 
high doses.63  

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Figure 2.4. Magnesium Site and Mechanism of Action 
Source: Warner DS, Herroeder S, Scho ME. Magnesium — Essentials for 
Anesthesiologists. 2011; (4) 
Magnesium is important for regulating the flow of essential ions such as potassium 
and calcium within cells. If the magnesium level is too low, potassium will easily 
escape from the cell, interfering with cell function and metabolism. Magnesium 
also affects the movement of calcium through specialized channels in the cell 
membrane and within the sarcoplasma reticulum, the main place of calcium storage 
in cells. Magnesium acts like a "gatekeeper" that slows the entry of calcium and 
prevents the excretion of excess calcium from the sarcoplasmic reticulum. As a 
result, if magnesium deficiency (hypomagnesemia) occurs, calcium levels in the 
cells can actually increase.60 
Magnesium sulfate as mentioned earlier, is a kind of noncompetitive NMDA 
receptor antagonist, which has a central sedative, neuroprotective, and analgesic 
saving-effect.63,65 Its mechanism that is antagonistic to NMDA causes the inhibition 
of the entry of calcium to neurons and prevents other neurotransmitters from being 
released, as well as activating neuronal aptoptosis. Reduced release of 
catecholamines from the adrenal marrow and the antagonistic effects of calcium on 
vascular smooth muscle cells may also contribute to the effects of magnesium 
anesthesia. This effect makes magnesium sulfate one of the controlled hypotension 
agents that is quite effective in cases of synasal surgery.66 In the case of 
neuromuscular blockade, inhibition of calcium-mediated acetylcholine release from 
presynaptic nerve terminals in the neuromuscular junctio plays an important role. 
Decreased postsynaptic sensitivity to acetylcholine and direct effects on myocyte 

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membrane potential may also contribute to the potentiating effects of 
neuromuscular blockade.61,63  
The work of NMDA receptors with neuroprotective and anticonvulsant properties 
of magnesium sulfate can reduce the incidence of agitation of recovering 
consciousness. It is widely reported that magnesium sulfate reduces the 
consumption of propofol, neuromuscular inhibitors, and morphine postoperatively 
in gynecological surgical patients. In another study involving gynecologic patients 
undergoing laparotomy under TIVA, pain scores, analgesic consumption, and the 
incidence of chills were lower in the magnesium group compared to the control 
group, and it was concluded that magnesium sulfate improved the quality of 
postoperative analgesia during TIVA.1,9,62,63 
2.3.3 Dosage and Drug Interactions 
Magnesium (Mg) can be given orally or through intravenous (IV) injections. 
Administration via intramuscular injection is also possible although it can cause 
pain. Daily doses of magnesium given orally of more than 50 mmol can cause 
vomiting and diarrhea. In anesthesia and intensive care, IV administration is 
preferred. There are two forms of magnesium that can be injected, namely 
magnesium chloride and magnesium sulfate. Ten milliliters of 10% magnesium 
chloride solution provide 1 gram of Mg salt (118 mg Mg), while 10 mL of 10% 
magnesium sulfate solution also provides 1 gram of Mg salt (98 mg Mg).60 
The dosage of magnesium is adjusted based on medical needs. To overcome 
magnesium deficit, a slow infusion of up to 10 grams per day is recommended. In 
use for pharmacological effects, a rapid infusion of 1-2 grams of MgSO4 for ten 
minutes, followed by a continuous infusion of 0.5-1 grams per hour (or 0.25 grams 
per hour for patients with kidney problems) is required to achieve the desired 
plasma concentration. Its use as intraoperative analgesia can be given at a loading 
dose of 30–50 mg/kg and continued infusion at 6–20 mg/kg/h until postoperatively 
or for 4 hours after the loading dose.65,67 In obese patients with a BMI of 30-45 its 
use can be used either actual weight or corrected weight because there is no 
significant difference in the effect of its analgesia and the increase in its magnesium 
levels.68  

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Electrocardiography monitoring to serum magnesium concentration measurements 
are routinely performed in patients who are given magnesium, especially at large 
doses. The use of magnesium for tocolysis showed side effects such as fever and 
headache more frequently at high doses (5 g per hour) than at low doses (2 g per 
hour), with more cases of pulmonary edema in the high-dose group. However, in 
the MAGPIE trial, the risk of pulmonary edema between the magnesium and 
placebo groups recorded no significant difference. In another study, it was said that 
an intravenous regimen with an initial dose of 8 grams for 60 minutes followed by 
2 grams/hour for 10 hours and 12 grams for 120 minutes followed by 2 grams/hour 
for 8 hours would produce magnesium concentrations below the toxic range. 
Another study comparing a dose of 2 g/hour with 1 g/hour, showed side effects at 
doses of 2 g/hour more frequently. However, the side effects caused are mild such 
as nausea, vomiting, dizziness, and redness without severe side effects. In this study 
of both groups, only 16% of the 2/hour dose group achieved magnesium levels of 
4-7 meq/mL. From several studies that have been described, it can be said that 
magnesium sulfate has a wide therapeutic index so that its safety is quite good 
45,60,67,69 
Magnesium abnormalities in the blood or dysmagnesemia can be in the form of 
hypermagnesemia or hypomagnesemia. Hypomagnesemia, defined as plasma 
magnesium levels below 0.7 mmol/L, can be caused by a variety of factors such as 
inadequate intake, impaired intestinal absorption, or increased renal excretion. 
Symptoms of hypomagnesemia are often non-specific and can overlap with other 
electrolyte disorders. Common clinical manifestations include muscle weakness, 
positive Trousseau and Chvostek signs, hypokalemia, and hypocalcemia.60,61  
Magnesium is generally very safe for cardiovascular. Excessively high magnesium 
levels (hypermagnesemia) are rare, except in people with kidney disorders who are 
exposed to additional sources of magnesium. In the treatment of seizures due to 
eclampsia, the magnesium level that is considered beneficial is 4-8 mg/dL. If the 
level is above 9 mg/dL, magnesium is considered harmful. Early symptoms of 
magnesium poisoning are usually loss of knee reflexes (at 12 mg/dL), nausea, 
warmth, redness, drowsiness, double vision, glare speech, and weakness. Muscle 
paralysis and respiratory failure can occur at levels of 15-17 mg/dL, while cardiac 

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arrest at levels exceeding 25 mg/dL. Thus, in the administration of magnesium, 
especially in large doses, it is necessary to monitor electrocardiography, respiration, 
urine production, and tendon reflexes. There have been two reports of magnesium 
poisoning: the first was due to receiving 13 grams of magnesium through an IV for 
40 minutes during surgery, and the second was due to the mistake of giving 25 
grams of magnesium sulfate (which should have been 4 grams). When 
hypermagnesemia occurs, the main treatment is to stop the intake of additional 
magnesium. In emergency conditions, such as life-threatening neurological and 
cardiovascular complications, calcium infusions may be given temporarily to 
counteract the effects of magnesium. Calcium doses can be administered at about 
2.5-5 mmol or 15 mg/kg through intravenous infusion slowly with a slow bolus 
with a rate exceeding 10 minutes or some sources do so with continuous infusions 
of 4 hours, until the heart's electrical conduction disorders disappear.60,67,70,71 
Drug interactions need to be thought about when using magnesium sulfate. 
Magnesium sulfate can interact synergistically with hypnotic anesthetic agents 
(sevoflurane and propofol) and non-depolarizing relaxants, thereby reducing the 
dose of the drug administered. A meta-analysis showed that magnesium 
administration can accelerate onset and prolong the duration of rocuronium's 
action.72,73 Calcium interacts antagonistically with magnesium sulfate, even 
becoming an antidote in cases of magnesium poisoning. Administration, along with 
antiarrhythmia drugs, needs to be careful, especially in calcium channel blockers 
which can synergistically lower blood pressure. The use of some types of 
corticosteroids can reduce serum magnesium levels.63 
The benefits of magnesium for postoperative analgesia are not limited to general 
anesthesia. Recent studies suggest that magnesium sulfate may also have a 
beneficial role in spinal anesthesia when administered through the intravenous or 
intratecal route. Magnesium can prevent the induction of central sentivity from 
peripheral nociceptive stimuli at the spinal action site by inhibiting NMDA 
receptors. By the same mechanism, when small doses of magnesium sulfate are 
added to local anesthesia for spinal anesthesia, the duration of anesthesia becomes 
longer, the need for postoperative analgesics is reduced, and the side effects of high 
doses of local anesthesia and opioids can be reduced.74,75 Intraoperative use of 

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magnesium sulfate may be associated with a reduced incidence of nausea and 
vomiting after surgery which may be due to the lower use of a volatile anesthetic 
(sevoflurane) than the antiemetic effect of magnesium sulfate itself.62 
Magnesium sulfate also needs to be administered carefully by an anesthesiologist. 
The use of magnesium sulfate can cause cardiovascular depression by acting as a 
calcium channel blocker. The inhibition reduces the release of catecholamines 
thereby reducing the concentration of epinephrine and norepinephrine in plasma 
after endotracheal intubation, and thus reduces the hypertensive response during 
anesthesia induction. The use of magnesium sulfate should be done with caution in 
hypovolemic patients and in patients with limited cardiac capacity. In addition, an 
initial dose of magnesium sulfate at a slow pace (>10 minutes) can minimize 
cardiovascular side effects such as hypotension and bradycardia.62 
2.3.4 Contraindications 
Absolute and relative contraindications to magnesium sulfate administration 
include allergy to magnesium supplementation, atrioventricular block, and 
neuromuscular diseases such as myasthenia gravis.61 

31 
 
 
  
University of Indonesia 
 
2.4 
Theoretical Framework 
 
Figure 2.5 Theoretical Framework 
 
 
Pasien menjalani operasi
Durasi operasi
panjang
Anestesi
umum
Jenis Operasi
•
Otorhinolaringologi
•
Tulang punggung
•
Kardiotoraks
•
Abdomen
•
Bedah mulut
•
Payudara
Agitasi Pulih Sadar
Faktor Risiko:
•
Obesitas
•
Usia geriatri
•
Gangguan
psikologis
•
Laki-laki
•
Merokok
Sensasi tercekik
dan instrumentasi
Imbalans
impuls
inhibisi dan 
eksitasi
Proses 
Neuroinflamasi
Antagonis
NMDA
Alpha 2 central
Sedatif
MgSO4
Dexmedetomidine
Analgesia
Antagonis
NMDA
MgSO4
Alpha 2 central
Dexmedetomidine
Non Farmakologis
•
Minimal penggunaan alat-alat invasif yang
terpasang
•
Informasi yang cukup seputar ekspektasi nyeri
(-)
(-)
(-)
Keadaan
hiperarousal
fase 2 
pemulihan
Nyeri 
perioperatif
Penggunaan
anestesi
inhalasi
(+)
Penggunaan
relaksan
Reversal tidak
adekuat
(+)
Efek Samping
•
Hipotensi
•
Bradikardia
•
Pemanjangan durasi
ekstubasi
•
Jumlah
fentanyl
perioperatif
•
Skor
numerik
nyeri
pascaoperasi
Penggunaan
benzodiazepine
(+)
Operasi urgensi
atau emergensi
(+)

32 
 
 
  
University of Indonesia 
 
 
2.5 
Concept Framework 
 
 
Figure 2.6 Concept Framework 
 
Kejadian agitasi pulih sadar
•
Proporsi kejadian Agitasi. 
Agitasi bila SASR > 1
•
Onset terjadi agitasi
•
Durasi agitasi
•
Penggunaan propofol pada 
agitasi berat
Pemberian adjuvan
anestesi
•
Dexmedetomidine
•
Magnesium sulfat
Efek samping
Parameter 
Hemodinamik
•
Tekanan
rerata
arteri
•
Frekuensi
nadi
Durasi lama 
Ekstubasi
Faktor operasi
•
Jenis operasi
otorhinolaringologi
•
Durasi operasi panjang
Status nyeri pasca operasi
•
Nyeri bila skala analog 
visual > 4
•
Penggunaan fentanyl
perioperatif
Penggunaan agen inhalasi
anestesi
Komorbid pasien
•
Status obesitas (indeks
massa tubuh >30 kg/m2)
•
Usia geriatri >65 tahun
•
Gangguan psikologis yang 
mendapatkan terapi, 
berupa antidepresif atau
ansiolitik
•
Perokok
Variabel Independen
Variabel Dependen
Variabel Perancu

 
33 
 
   University of Indonesia 
 
BAB 3 
 
RESEARCH METHODS  
 
3.1 
Research Design 
The research design to be used is a controlled randomized trial design. This study 
will be conducted prospectively with sample allocation carried out randomly using 
random numbers on the randomization tool (randomization device according to 
www.randomizer.org). The data collection of this research will be carried out in a 
double disguise where the sample and the data taker, in this case the researcher, do 
not know the type of treatment obtained. In this study, those who know the 
treatment are third parties who are not involved in data collection and analysis. 
 
3.2 
Place and Time of Research 
The research will be carried out in the operating room of the Kanigara National 
Central General Hospital (RSUPN) dr. Cipto Mangunkusumo and the central 
surgical installation of the University of Indonesia Hospital (RS) for 3 months. 
Sampling began in April 2024 to June 2024 after the ethics and location review was 
passed 
 
3.3 
Population and Research Sample 
The target population of the study is adult patients who will undergo elective 
otorhinolaryngology region surgery. The affordable population in this study was 
adult patients undergoing otorhinolaryngology elective surgery in the Kanigara 
operating room of Dr. Cipto Mangunkusumo Hospital and the central surgical 
installation of the University of Indonesia Hospital. The research sample was adult 
patients who underwent otorhinolaryngology elective surgery in the Kanigara 
operating room of Dr. Cipto Mangunkusumo Hospital and the central surgical 
installation of the University of Indonesia Hospital from April to June 2024 who 
met the inclusion criteria and were not excluded by sample selection using a random 
sampling method. 

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3.4 
Inclusion and Exclusion Criteria 
3.4.1 Inclusion Criteria 
a. Adult patients 18 – 70 years old 
b. ASA elective surgical patients 1 and 2 
c. Undergoing a general anesthesia procedure 
3.4.2 Exclusion Criteria 
a. Pregnant patients 
b. Patients with severe cognition impairment and decreased consciousness 
c. Patients refuse to participate in the study 
d. Patients allergic to medications used throughout the study 
e. Patients with contraindications to the administration of intervention 
agents: atrioventricular block, sinoatrial node dysfunction, renal failure 
f. Patients with neuromuscular disorders 
g. Patients with regular consumption of beta-blockers or clonidines 
h. Postop patients are not extubated in the operating room or in the PACU 
i. Patients with BMI ≥ 40 
3.4.3 Production Criteria 
a. Serious adverse events (mortality and serious morbidity) 
b. Postoperative patients with no plans to the ICU on a ventilator  
 
3.5 
Large Sample 
The sample size needed for each group in this study is based on the sample size 
formula of comparative analysis of unpaired categorical variables. 
Large sample size of unpaired categorical variables: 
 
n1 = n2 = (
(𝑍1−𝛼 + 𝑍1−β)2 (𝑃1(1−𝑃1)+𝑃2(1−𝑃2))
(|𝑃1−𝑃2|−∆)2
) 
n1 = n2 = sample size in one of the groups  

35 
 
 
  
University of Indonesia 
 
N = 2n = total sample size 
Alpha (α) = Type one error, set to 5% 
Zα = 5% alpha standard value, i.e. 1.64 
Beta(β) = Type two error, set 20% 
Zβ = The standard beta value is 20%, which is 0.84. 
P1 = Proportion of magnesium sulfate group. The proportions are set to be 
equivalent to dexmedetomidine   
P2 = Proportion of dexmedetomidine group = 0.056 (Salman)1  
∆ = The maximum margin of difference set so that magnesium is considered 
not inferior to dexmedetomidine. Researchers set 0.15  
 
So with this value is obtained: 
n1 = n2 = = 29 (
(1.64+ 0.84)2 (0.056(1−0.056)+0.056(1−0.056))
(|0.28−0.28|−0.15)2
) 
 
Based on the formula above, the sample size was 29 people per group and 
added 10% drop out, so that the total number of samples was 64 (32 samples 
per 
group). 
 
 
3.6 
Tools and Workpieces 
1. Work Tools 
a. Spray 50 mL 
b. Spray 3 mL 
c. Syringe 5 mL 
d. Spray 10 mL 
e. Perfuser pipe 

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University of Indonesia 
 
f. Syringe pump 
g. Non-invasive blood pressure, pulse frequency, oxygen saturation, end-
tidal carbon dioxide and electrocardiogram 
h. Anesthesia machine with oxygen and compressed air source 
i. Intravenous catheter  
j. Syringe 18 G 
k. Endotracheal pipe no 7.0/7.5 
l. Stationery 
m. Research form 
 
2. Workpiece 
a. Kabimidin® 100 mcg/mL 
b. MgSO4 20% 
c. NaCl 0.9% 100 mL 
d. Paracetamol 1000 mg IV preparation 
e. Ketorolak 30 mg/mL 
f. Fentanyl 50 mcg/mL 
g. Sevofluran 
h. Propofol 10 mg/mL 
i. Rocuronium 10 mg/mL 
j. Ephedrine 10 mg/mL 
k. Dexamethasone 5 mg/mL 
l. Metoclopramid 5 mg/mL 
m. Neostigmine 0.5 mg/mL 
n. Sulphas atropine 0.25 mg/mL 
o. Calcium gluconase 100 mg/mL 

37 
 
 
  
University of Indonesia 
 
3.7 
Research Flow 
  
Subjek dievaluasi
untuk kelayakan
Dieksklusikan
Randomisasi
Pendaftaran
Alokasi
Kelompok A
(pemberian
Magnesium sulfat)
Kelompok B
(pemberian
Dexmedetomidine)
Ruang operasi
Pengukuran parameter hemodinamik prainduksi: tekanan rerata arteri dan frekuensi nadi
Induksi Anestesi: propofol 1-2.5 mg/kg, fentanyl 2 mcg/kg, rocuronium 0.6 mg/kg
Pemeliharaan anestesi: sevofurane 1.2 – 2.2 vol% atau MAC 0.6 – 1.1
Analgetik postop: paracetamol 1 g IV dan ketorolac 30 mg IV
Antiemetik: dexametason 5 mg Iv dan metoclopramide 10 mg IV
Luaran
Intraoperatif:
•
Tekanan darah
rerata dan frekuensi
nadi
•
Durasi operasi
•
Jumlah pemberian
efedrin
•
Jumlah fentanyl
•
Jumlah sevoflurane
•
Kejadian yang tidak
diharapkan
Postoperatif:
•
Agitasi kembali
pulih
•
Penggunaan
propofol
•
Jumlah fentanyl
•
Skala nyeri numerik
•
Lama ekstubasi
•
Kejadian yang tidak
diharapkan
Analisis
Ruang perawatan
•
Pencatatan demografis pasien berupa: berat badan, tinggi badan, usia, dan jenis kelamin
•
Pencatatan riwayat gangguan psikologis dan status perokok
•
Pengukuran parameter hemodinamik dasar: tekanan rerata arteri dan frekuensi nadi
Kelompok A
Magnesium sulfat
dijalankan dengan
kecepatan 20 
mg/kg/jam sejak
induksi hingga tindakan
selesai
Kelompok B
Dexmedetomidine 
dijalankan dengan
kecepatan 0.5 
mcg/kg/jam sejak
induksi hingga tindakan
selesai

38 
 
 
  
University of Indonesia 
 
3.8 
Research Procedure 
1. Recruitment of subjects will begin after passing the ethics review and exit 
location permits 
2. Patients who meet the inclusion criteria and do not meet the exclusion 
criteria will be given an explanation by the researcher. Patients are taken as 
research subjects after being educated to understand the researcher's 
explanation, approve, and sign the research approval sheet. 
3. Randomization is done by a third party, who is not involved in the research 
process, to determine the type of treatment to be given. Randomization is 
carried out using random numbers on the randomization tool (randomization 
device according to www.randomizer.org). The treatment obtained can be 
divided into 2 groups with a ratio of 1:1, namely group A who received 
Dexmedetomidine therapy and group B who received 10% Magnesium 
sulfate. The results of this randomization were placed in a numbered 
envelope which was then handed to the researcher. In this case, the 
researcher does not know each of the contents of the envelope. This 
envelope, which contains the type of treatment given, is then handed over 
to the pharmacy team before starting anesthesia.  
4. An instruction sheet on how to mix treatment drugs is handed over to the 
pharmacy team. The instruction sheet contains a speed formula that gives 
the same speed results between the 2 groups, so the type of treatment is 
unknown to the researcher and the anesthesia team (figure 4). The 
pharmaceutical team compounded the drugs according to the instructions 
which were then labeled with the patient's identity and the label "Research 
Drugs dr. Yunda" with calculated speed and research number.  

39 
 
 
  
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Figure 3.1. Instructions on How to Compound Research Drugs 
The division of this therapy or treatment is unknown to the anesthesia team 
and the research team. As long as the action is the data is taken and recorded 
by the researcher, not by the anesthesia team. 
5. The anesthesia procedure will be performed with the researcher and the 
anesthesia team of the operating room. The anesthesia team here is tasked 
with providing ventilation, intubating, and maintaining the condition of 
intraoperative patients. Researchers, in addition to data loggers, will be in 
charge of entering induction drugs and research drugs. Before the patient is 
pushed into the operating room, a venous access with the number 18 or 20 
G is installed. 
6. Upon arrival at the operating room. The patient was fitted with monitoring 
devices, in the form of: non-invasive blood pressure, ECG, oxygen 
saturation, etCO2, and temperature. The researcher as a data taker will 
record the values of the average arterial pressure parameter and pulse 
frequency before induction. All treatment therapies, both group A and B are 
initiated when the patient is induced without using the initial charge dose. 
7. After the monitor is installed and the treatment drug is ready to be installed 
in the patient's infusion, the research drug begins as soon as the patient starts 
preoxygenation 100% oxygen flow of 6 liters per minute with a duration of 
3 minutes. After 3 minutes after administering the study drug, subjects were 
CARA PERACIKAN OBAT PENELITIAN DR. YUNDA
Alat dan Bahan: Spuit 50 mL, NaCl 0.9% 100 mL, needle 18 G, perfusor/tabung ekstensi no 1, dan
obat penelitian
Bila mendapatkan amplop Dexmedetomidine (200 mcg/2 mL):
1. Spuit 50 mL diisi dengan 1 mL Dexmedetomidine dan 39 mL NaCl 0.9%. Konsentrasi saat ini 2.5
mcg/mL
2. Hitung kecepatan dosis 0.5/mcg/kg/jam dengan rumus berikut:
= 
= xx mL/jam
3. Tuliskan kecepatan obat di label yang telah disediakan
Bila mendapatkan amplop MgSO4 20% (5 g/25 mL):
1. Spuit 50 mL diisi dengan 20 mL MgSO4 20% dan 20 mL NaCl 0.9%. Konsentrasi MgSO4 saat ini
100 mg/mL atau MgSO4 10%
2. Hitung kecepatan dosis 20 mg/kg/jam dengan rumus berikut
= 
= xx mL/jam
3. Tuliskan kecepatan obat di label yang telah disediakan

40 
 
 
  
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given fentanyl opioids 2 mcg/kg IV body weight as coinduction and 
propofol titration induction agent 1-2.5 mg/kg body weight. Before being 
inserted into the relaxant, a neuromuscular monitor in the form of a train of 
four (TOF) was installed. Then it was followed by the administration of 
rocuronium 0.6 mg/kg. Before inserting the laryngoscope, propofol is given 
again at 0.3-0.5 mg/kg according to the patient's pulse rate and blood 
pressure. Then the anesthesia team intubated with ETT number 7.5 for men 
and 7.0 for women. Once intubated, sevoflurane can be delivered with a 
clinically appropriate target, MAC 0.6-1.1 or 1.2 – 2.2 vol%. The subjects' 
hemodynamic parameters, in the form of mean arterial pressure and pulse 
frequency were recorded by the researcher after induction and 
postintubation drug administration. 
8. After the subjects were intubated, dexamethasone 5 mg IV was administered 
for the prevention of postoperative occurrence of nausea and vomiting. The 
administration of paracetamol 1 gram IV postoperative analgesia was also 
given within 30 minutes after intubation. Researchers recorded mean 
arterial pressure and pulse frequency shortly after the incision and 30 
minutes post-incision 
9. During the action, the maintenance of the depth of anesthesia is 
administered sevoflurane MAC 0.6-1.1 or 1.2 – 2.2 vol%. Fentanyl 
administration of 1 mcg/kg of body weight and rocuronium 0.2 mg/kg of 
body weight can be administered intraoperatively when deemed necessary. 
The ventilator is set in pressure or volume mode with a tidal volume of 6-8 
mL/kg body weight and its breathing rate is set to the normocarb target 
(etCO2 35 – 45 mmHg). During intraoperatively, the average arterial 
pressure was kept from falling beyond 30% of baseline and the pulse rate 
did not drop <50 times per minute or drop more than 30% from baseline in 
the healthy adult population with an initial pulse value of 50-60 times per 
minute. If this happens, then the management is in accordance with the 
intraoperative emergency protocol. Ephedrine use is recorded over time. 
The temperature is also maintained in the range of 36 – 370 C. The 

41 
 
 
  
University of Indonesia 
 
temperature will be maintained by providing a warming mat, a convective 
forced heating device, and warm infusion. 
10. Study subjects will be given 10 mg metocloromidi for the prevention of 
nausea and vomiting and 30 mg IV ketorolac for postoperative analgesia at 
surgical completion and before extubation. 
11. When the action was completed, the study subjects were given a 
neuromuscular block reversal agent in the form of neostigmine 0.04 mg/kg 
and sulphas atropine 0.02 mg/kg if the TOF count was 4 and the TOF ratio 
was at least 0.4. After that sevoflurane and research drugs were discontinued. 
An air flow of 6 liters per minute is set to drain out the sevoflurane. After 
the tidal volume was reached 6 mL/Kg with etCO2 35-45 and the subject 
responded to verbally, the subjects were consciously extubated without 
being stimulated by previous pain stimuli or repeated patting. Stimulation 
that can only be done is in the form of verbal stimulation or occasional touch. 
12. The incidence of agitation recovering consciously was recorded in the form 
of a SASR score by the researcher. The zero time of agitation measurement 
is when the anesthetic gas is stopped and the end time is 30 minutes post-
extubation. The SASR score recorded was the highest score in patients. 
When agitation occurs, namely SASR ≥1, the researcher records the onset 
and duration of agitation. If there is agitation that endangers the patient and 
the medical team with a SASR scale of ≥+3, the researcher or anesthesia 
team gives propofol 0.3 - 0.5 mg/kg body weight and can be repeated until 
calm. The number of doses of propofol used were recorded by the 
researchers. The length of the extubation was also calculated and recorded 
in the research sheet by the research team at the time the drug was 
discontinued until the patient could be extubated.  
13. Patients were pushed to the recovery room or PACU to be evaluated for 
postoperative pain with a numerical pain assessment scale and re-evaluation 
of mean arterial pressure and pulse frequency 1 hour postoperatively. While 
at PACU, patients were also tested for tendon reflexes and muscle strength. 
If hyporeflexes and areflex occur, calcium gluconas as much as 15 mg/kg is 
given with a slow bolus of >10 minutes and the patient's magnesium levels 

42 
 
 
  
University of Indonesia 
 
are checked. Patients can move to the room if the Aldrette score is ≥9 after 
1 hour of observation 
3.9 
Perioperative Disorder Management Protocol 
3.9.1 Intraoperative Hemodynamic Disorders Protocol 
 
  
Frekuensi nadi < 50 kali per menit atau turun
>30% nilai dasar*?
Apakah MAP turun
>30% dari nilai dasar?
Ya
Tidak
•
Titrasi turun perlahan
MAC gas sevoflurane, 
nilai minimum: 0.5 
MAC atau 0.8 – 1 
%volume
•
Pemberian efedrin 5 
mg bolus bila kadar
minimum sevoflurane 
(0.5 MAC) tercapai
atau terjadi hipotensi
•
Pemberian cairan cepat 5 mL/kgBB
dapat diulang hingga 2 kali
•
Titrasi turun MAC gas sevoflurane, 
minimum MAC 0.5 MAC atau 0.8 –
1 %volume
•
Pemberian efedrin 5 mg dapat
diberikan 3 kali dalam interval 5 
menit
•
Evaluasi penyebab: hypovolemia, 
anemia, anestesia terlalu dalam, 
anafilaksis
•
Evaluasi perubahan EKG: tanda-
tanda blok AV derajat 2 dan 3 atau
tanda hipermagnesemia
(gelombang T tinggi, pemanjangan
interval PR dan QTc, QRS melebar, 
dan nadi prematur )
Ya
Tidak
Lanjutkan
pemantauan
intraoperatif
Apakah masih terjadi
hipotensi?
Apakah ada kelainan
EKG?

43 
 
 
  
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44 
 
 
  
University of Indonesia 
 
  
Apakah masih terjadi
hipotensi?
Apakah terjadi tanda-
tanda anafilaksis?
•
Hipotensi
•
Perbedaan tekanan
pulsasi > 40 mmHg
•
Lesi kulit: urtikaria, 
angioedema
•
Mengi dengan
auskultasi atau
tekanan inspirasi >30 
mmHg
Lanjutkan
pemantauan
intraoperatif
Ya
Tidak
Apakah ada kelainan
EKG?
Terdapat AV blok
derajat 2 dan 3
Tanda-tanda
hipermagnesemia*
•
Cek elektrolit cito: 
kalium, 
magnesium, dan 
kalsium
•
Pemberian ca 
glukonas 1 gram IV
•
Pemberian atropine 
0.5 mg IV dapat
diulang 3 kali
•
Pemberian
dopamine 5-10 
mcg/kg/menit bila
atropine tidak
berefek
•
Hentikan operasi
•
Lakukan alat pacu 
transkutan
•
Pemberian bolus 
Ca glukonas1 g 
IV
•
Cek elektrolit
cito: kalium, 
magnesium, dan 
kalsium
•
Terapi sesuai
hasil elektrolit
Ya
Tidak
•
Evaluasi perdarahan
hingga pertimbangan
transfusi
•
Bila timbul akibat
rangsangan bedah
tertentu, 
komunikasikan ke
operator
•
Evaluasi kembali obat-
obat telah diberikan, 
apakah ada efek
sinergis
•
Obat penelitian
diturunkan setengah
dosis. Bila hipotensi
menetap, obat distop
•
Bila pemberhentian
obat penelitian tidak
efektif, mulai
norepinefrin 0.05 
mcg/kg/menit IV 
titrasi
•
Stop obat-obatan IV 
yang diterima pasien
•
Komunikasi ke operator 
untuk hentikan tindakan
hingga resusitasi selesai
•
Bila bronkospasme: 
inhalasi salbutamol 2.5 
mg 
•
Bila syok anafilaksis: 
•
Loading kembali
kristaloid 10-20 
mL/kgBB
•
Epinefrin 0.05 
mcg/kg/menit IV 
titrasi
•
Bolus 
difenhidramin 50 
mg IV
•
Bolus Ranitidin 50 
mg IV 
•
Pemberian
hidrokortison 100 – 200 
mg IV atau
dexametason 10 - 20 
mg IV
* Pada pasien dewasa sehat dengan nadi awal 50-60 kali per menit
** Gelombang T tinggi, pemanjangan interval PR dan QTc, QRS melebar, dan nadi prematur

45 
 
 
  
University of Indonesia 
 
3.9.2 Recovery of Consciousness Agitation Protocol 
 
3.10 
Operational Definition 
Independent Variables 
a. Subjects who get Dexmedetomidine 
b. Subjects who get MgSO4 
Dependent Variable 
a. Events of agitation regain consciousness after surgery 
b. The Onset of Conscious Agitation 
c. The duration of the agitation regained consciousness 
Skor SASR > 1
Ya
Tidak
Lanjutkan
observasi
Skor > 3
Ya
Tidak
•
Menenangkan pasien
•
Orientasi tempat dan 
waktu ke pasien
•
Evaluasi nyeri dan 
pemberian anti nyeri
Skor nyeri > 4
•
Propofol 0.3-0.5 mg/kg
•
Suplementasi oksigen saat
tersedasi
•
Pertahankan jalan napas 
saat tersedasi
•
Evaluasi kembali SASR saat
pasien sadar
Ya
Tidak
•
Fentanyl 1 mcg/kg
•
Observasi pernapasan 1 jam 
setelah pemberian fentanyl
•
Evaluasi skor nyeri 5 menit
pascapemberian fentanyl
•
Lanjutkan observasi nyeri
di ruang pemulihan atau
PACU dalam 1 jam

46 
 
 
  
University of Indonesia 
 
d. Intraoperative hemodynamic changes (mean arterial pressure and pulse rate) 
e. Perioperative fentanyl administration 
f. Administration of hemodynamic rescue drugs (ephedrine) 
g. Administration of the Heavy Conscious Recovery Agitation Rescue Drug 
(Propofol) 
h. Postoperative pain score in the numerical pain assessment scale 
i. Length of extubation time 
Perancu Variables 
a. Comorbid obesity 
b. Comorbid psychological disorders 
c. Geriatric comorbidities 
d. Gender 
e. Smoking habits 
f. Duration of operation 
g. Intraoperative sevoflurane dosage 
h. Types of Operations 
3.10.1 Variable Operational Definition 
Variable 
Definition 
How to Measure 
Scale 
Independent Variables 
Magnesium 
sulfate 
The group received 
an infusion of MgSO4 
of 20 mg/kg/hr at a 
concentration of 10% 
(no dose fit at the 
beginning).  
Patients were put 
into 
group 
A. 
Therapy was given 
during 
induction 
until the anesthetic 
gas 
(sevoflurane) 
was stopped. The 
drug label is written 
"Yunda 
research 
drug", the research 
number, the patient 
label and the speed 
Categorical  

47 
 
 
  
University of Indonesia 
 
of administration in 
mL/hour 
Dexmedetomidine The group received 
an 
infusion 
of 
dexmedetomidine of 
0.5 
μg/kg/hour 
(without a loading 
dose at baseline). The 
use 
of 
dexmedetomidine is 
used as a standard 
reference 
for 
the 
prevention 
of 
agitation 
and 
recovering 
consciousness In this 
study 
using 
Kabimidin® 
Patients are placed in 
group B. Therapy is 
given 
during 
induction until the 
anesthetic 
gas 
(sevoflurane) 
is 
stopped. The drug 
label reads "research 
drug", the patient's 
identity 
and 
the 
speed of the recipient 
in mL/hour 
Categorical  
Dependent Variable 
Agitation 
regained 
consciousness 
The 
dependent 
variable of conscious 
recovery 
agitation 
was 
operationally 
defined 
with 
a 
measurable 
SASR 
value of >+1 from the 
time the patient was 
stopped 
from 
inhalation anesthesia 
up to 30 minutes 
post-extubation 
Patients are assessed 
by 
the 
anesthesia 
team with patient 
outputs 
will 
be 
categorized as  
1. Yes 
(Experiencing 
Agitation, 
Recover 
Consciousness)  
2. No 
(not 
experiencing 
agitation, 
Categorical  

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regaining 
consciousness) 
The 
Onset 
of 
Conscious 
Agitation 
The 
first 
time 
conscious 
agitation 
occurred in patients 
with SASR 1-2 
Onset is calculated 
when the anesthetic 
drugs and the study 
drug 
are 
stopped 
together up to 30 
minutes 
after 
extubation. Onset is 
measured in minutes 
and is presented in 
mean or median form 
in groups A and B 
Numerical 
The duration of 
the 
agitation 
regained 
consciousness 
The duration of the 
agitation 
is 
recovering 
consciously 
which 
can 
be 
overcome 
without the use of 
agitation 
rescue 
drugs. In  
The 
duration 
is 
calculated from the 
initial 
time 
the 
patient experiences 
agitation until the 
agitation stops. If 
there is a recurrent 
occurrence of mild 
agitation, 
the 
duration used is the 
longest. Duration is 
measured in minutes 
and is presented as 
mean or median in 
groups A and B 
Numerical 
Hemodynamic 
parameters 
The 
condition 
of 
circulatory dynamics 
during the procedure 
was in the form of 
The patient's output 
is illustrated with 
average 
arterial 
pressure and pulse 
Numerical  

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pulse frequency and 
average 
arterial 
pressure 
during 
intraoperative. 
This 
figure 
is 
obtained 
from 
the 
measurement of non-
invasive 
blood 
pressure of patients. 
Average 
arterial 
pressure is measured 
in mmHg while pulse 
frequency 
is 
measured in times per 
minute 
rate. 
Recorded 
values: 
1. 
Basic values  
2. 
Pre-induction 
values 
3. 
After induction 
4. 
After intubation 
5. 
After 
the 
incision 
6. 
30 minutes after 
incision 
7. 
After 
extubation 
8. 
At 
one 
hour 
postoperatively 
 
Minimum, 
maximum, 
and 
median 
or 
mean 
values 
will 
be 
presented in the data. 
Hemodynamic 
rescue drugs 
Medication 
given 
when 
hypotension 
occurs 
(average 
blood 
pressure 
drops >30% base) or 
bradycardia 
occurs 
(pulse <50 times per 
minute). In this study, 
the drug in question 
was ephedrine 5 mg 
IV 
The use of ephedrine 
as much as 5 mg IV 
will be recorded by 
the anesthesia team 
the amount of each 
time 
it 
is 
used 
(frequency 
of 
administration) and 
at 
any 
time 
of 
administration. The 
total 
amount 
of 
Numerical  

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ephedrine per action 
will be presented in 
mean or median form 
in groups A and B. 
Agitation rescue 
drugs 
regain 
consciousness 
Drugs are given in the 
event of conscious 
recovery 
agitation 
that has the potential 
to harm both patients, 
medical staff, or the 
release of medical 
instruments that still 
need 
to 
be 
maintained. 
Objectively, the score 
value that is said to be 
harmful is the SASR 
score ≥3. In the study, 
the agent used was 
propofol 
0.3-0.5 
mg/kg and could be 
repeated 
until 
the 
patient calmed down 
with SASR 0  
The use of propofol 
will be recorded for 
each administration 
and the amount is 
accumulated for each 
subject 
to 
get 
propofol up to SASR 
0. 
Data 
will 
be 
presented with mean 
and median doses of 
propofol 
used 
in 
groups A and B 
Numerical 
Postoperative 
pain score 
The assessed pain 
score 
uses 
a 
numerical 
pain 
assessment 
scale 
measured on a scale 
of 0 to 10 to describe 
the intensity of pain 
when 
the 
patient 
Patients were asked 
objectively by the 
anesthesia 
team 
using a numerical 
pain 
assessment 
scale upon arrival in 
the 
postoperative 
room. Patients were 
Categorical 

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arrives 
at 
the 
recovery room 
asked to describe 
their pain on a scale 
of 0 to 10. A scale of 
0 patients had no 
pain at all, for a scale 
of 10 the pain was 
very 
severe 
and 
unbearable. Pain was 
then classified into: 
pain (pain numerical 
rating scale > 4) and 
non-pain numerical 
rating scale of pain < 
4) 
Perioperative 
opioid use 
Number of doses of 
intravenous fentanyl 
use 
during 
the 
intraoperative 
and 
postoperative periods  
It is calculated from 
the time the patient is 
installed 
on 
the 
monitor 
in 
the 
operating room (zero 
time) until the patient 
moves to the room. 
Total dose usage is 
calculated 
in 
micrograms (mcg). 
Its 
use 
will 
be 
compared in mean or 
median 
form 
in 
groups A and B 
Numerical 
Extubation 
duration 
The length of time the 
patient 
can 
be 
consciously 
The time will be 
measured 
by 
the 
anesthesia team as 
soon as the patient is 
Numerical  

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extubated 
after 
receiving therapy 
stopped 
from 
the 
flow of anesthesia 
gas 
and 
stopped 
when the patient is 
awakely 
removed 
from 
the 
endotracheal 
tube. 
Data is presented in 
the form of minute 
units in groups A and 
B 
Disruptive Variables 
Obesity 
Patients were defined 
by a body mass index 
(BMI) > 30 kg/m2 
calculated 
by 
the 
formula: body mass 
in 
kilograms 
(kg) 
divided by height in 
meters (m) squared 
Patients are grouped 
into 2 groups: 
1. Obesity (BMI > 
30) 
2. Not obese (BMI 
< 30) 
Categorical  
Psychological 
disorders 
The 
patient 
has 
previously 
been 
diagnosed 
with 
neurotic 
disorder 
(generalized anxiety 
disorder) 
or 
depression 
by 
a 
doctor and received 
regular therapy 
Patients are grouped 
into 2 groups: 
1. With distractions 
2. Uninterrupted 
 
Categorical  
Geriatrics 
Patients, both women 
and men, who are 
over 60 years of age 
Patients are grouped 
into 2 groups: 
1. Geriatrics 
Categorical  

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2. Non-geriatric 
Smokers 
Female 
or 
male 
patients 
who 
regularly 
consume 
tobacco 
products, 
such as cigarettes, 
cigars, 
rolling. 
E-
cigarettes 
and 
chewable nicotine do 
not fall into this 
category 
Patients are grouped 
into 2 groups: 
1. Smokers 
2. Non-smokers 
Categorical 
Intraoperative 
use of sevoflurane 
The 
use 
of 
sevoflurane 
for 
maintenance 
of 
anesthesia during the 
procedure 
Zero time when the 
endotracheal tube is 
fixed 
and 
sevoflurane is turned 
on first until the flow 
of 
sevoflurane 
is 
stopped when the 
action is completed. 
Units 
measured: 
MAC, 
liters 
per 
minute, 
and %volume 
Numerical 
Duration 
of 
operation  
The length of the 
duration 
of 
the 
surgery experienced 
by the patient. 
It is calculated from 
the time the patient is 
initiated (zero time) 
until 
the 
surgical 
wound is completed. 
Units in minutes and 
presented in mean or 
median 
form 
in 
groups A and B 
Numerical  

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Type of operation Otorhinolaryngology 
patients are divided 
into 
otological 
surgery (ear area), 
rhinology (nose and 
sinus 
area), 
and 
laryngology 
(pharyngeal 
and 
laryngeal area) 
Patients are put into 
the 
appropriate 
classification of the 
type of surgery. The 
amount 
will 
be 
calculated. 
The 
proportion 
of 
otology, rhinology, 
and 
laryngology 
patients 
will 
be 
compared in groups 
A and B 
Categorical 
 
3.10.2 Operational Definition of Term 
Terms 
Operational Definition 
Otorhinolaryngology surgery 
All surgical procedures are performed on 
the ear, nose, and throat regions. The 
action can be both invasive and 
minimally invasive. Some examples of 
actions that enter this definition:  
• Prhinology 
Septoplasty, 
rhinoplasty, 
sinus 
endoscopic 
functional 
surgery, 
dakriosistorhinostomy, 
turbinoplasty, 
sphenoidoidectomy, 
turbinoplasty, polypectomy, mass 
excision with minimal risk of 
bleeding, palatoplasty, mass biopsy 
• Otology 
Tympanoplasty, 
miringotomy, 
otoplasty, 
fistulectomy, 
mass 

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University of Indonesia 
 
excision with minimal risk of 
bleeding, mastoidectomy, Grommet 
tube 
insertion, 
mass 
biopsy, 
meatoplasty, 
canaloplasty, 
and 
auriculoplasty 
• Laryngology 
Polypectomy, tonsiladenodectomy, 
uvulopalatopharyngoplasty, 
diagnostic laryngoscopy or mass 
extraction, 
laryngoplasty, 
mass 
excision with minimal risk of 
bleeding, mass biopsy 
The actions taken are not extensive to 
include orbitotomy or opening the 
duramater.  
Agitation regained consciousness 
General 
postanesthesia 
psychomotor 
incidence measured with SASR ≥ 1: 
• Combative: Overtly resisting, 
aggressive, a direct threat to staff. 
Score 4 
• Very 
agitated: 
Pulling 
or 
removing the endotracheal tube 
or catheter; be aggressive. Score 
3 
• Agitated: 
Aimless 
frequency 
movements, 
against 
the 
ventilator. Score 2 
• Restless: 
Anxious 
but 
not 
aggressive or strong. Score 1 
Its zero time was measured when 
sevoflurane gas and the research drug 
were stopped simultaneously for up to 30 

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University of Indonesia 
 
minutes after the endotracheal tube was 
pulled out 
Effective 
Therapy is said to be effective when the 
preventive effect of conscious recovery 
agitation is achieved as well or better 
than the best standard with the same or 
fewer side effects compared to the best 
standard 
Basic values  
Mean arterial pressure values and pulse 
frequency measured 1 day before surgery 
at the time in the room 
Intraoperative 
hemodynamic 
disorders 
Common disorders are a pulse frequency 
of <50 times per minute or a 30% 
decrease in pulse frequency from 
baseline in healthy individuals with 50-
60 pulse frequency bradycardia and a 
decrease in mean arterial pressure >30% 
baseline 
Research drugs 
Drugs containing dexmedetomidine or 
magnesium sulfate that have been 
prepared by the pharmaceutical team. 
The researchers and the OK team do not 
know the exact content of the research 
drug. 
Numerical scale of pain 
A scale used to assess the degree of pain 
intensity. Subjects were asked to give a 
score from a score of 0 (no pain at all) to 
a score of 10 (the most unbearable pain) 
Severe cognitive impairment 
Patients who have been diagnosed with 
dementia in the geriatric population or 
severe mental retardation in non-geriatric 

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populations who need full assistance to 
manage their daily activities  
Deep tendon reflex 
An 
involuntary 
muscle 
contraction 
movement that is triggered when a reflex 
hammer is tapped into a specific tendon. 
In this study, it will be tested on the 
achilles tendon or patella. The results 
obtained can be in the form of: 
• Hyperreflex 
• Normorefleks 
• Hyporeflexes 
• Reflexes 
 
3.11 
Data Analysis Plan 
Data analysis will be carried out using a comparative hypothesis test (difference in 
proportion) using the Statistical Package for Social Sciences (SPSS) version 2.0. In 
this test, there were two groups that were not paired. The test test conducted on this 
subject is a two-proportion difference test using chi-square. A two-proportion 
difference test was also performed on secondary data in a categorical form in the 
group that received dexmedetomidine and that compared magnesium sulfate. In 
secondary data in the form of extubation duration and hemodynamic parameters of 
patients with a numerical scale, normality will be tested first with the Kolmogorov-
Smirnov test. Then if the results of the normality test obtain a normal distribution, 
then the data will be presented in the form of mean and standard deviation followed 
by the analysis test of the unpaired student t-test. If the distribution of data is 
abnormal, the data will be presented in median, minimum, and maximum forms 
followed by the Mann-Whitney statistical analysis test. 
3.12 
Research Ethics and Consent 
Researchers will submit proposals to obtain research ethics approval from the 
FKUI/RSCM Research Ethics Committee. The recruitment of research subjects is 
voluntary. All research subjects have the right to a complete explanation of the 

58 
 
 
  
University of Indonesia 
 
procedure of this research and have the right to refuse to participate in the research. 
Research subjects who are willing to participate in the research will be asked to sign 
an informed consent and can resign at any time. The entire population continues to 
receive services according to standards. 
 
 

59 
 
 
  
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3.13 
Research Timeline 
  
Table 3.1. Research Timeline 
Activities 
January 
2024 
February 
2024 
April 
2024 
May 
2024 
July 
2024 
Proposal creation 
 
 
 
 
 
Research ethics 
submission 
 
 
 
 
 
Managing location 
licensing 
 
 
 
 
 
Data collection 
 
 
 
 
 
Data analysis 
 
 
 
 
 
Creation of research 
reports 
 
 
 
 
 

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Amer GF, Abdallah MY. Dexmedetomidine versus propofol for prevention 
of emergence delirium in pediatric cataract surgery: Double blinded 
randomized study. Egypt J Anaesth. 2022; 38(1):300–4.  
59.  
Obara S. Dexmedetomidine as an adjuvant during general anesthesia. J 
Anesth. 2018; 32(3):313–5.  
60.  
Dubé L, Granry JC. The therapeutic use of magnesium in anesthesiology, 
intensive care and emergency medicine: A review. Can J Anesth. 2003; 
50(7):732–46.  
61.  
Warner DS, Herroeder S, Scho ME. Magnesium — Essentials for 
Anesthesiologists. 2011; (4).  
62.  
Do S. Magnesium : a versatile drug for anesthesiologists. 2013; 65(1):4–8.  
63.  
Sirvinskas E, Laurinaitis R. Use of magnesium sulfate in anesthesiology. 

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Medicine (Kaunas). 2002; 38(7):695–8.  
64.  Sharma P, Chung C, Vizcaychipi M. Magnesium: The Neglected Electrolyte? 
A Clinical Review. Pharmacol & Pharm. 2014; 05(07):762–72.  
65.  
Soleimanpour H, Imani F, Dolati S, Soleimanpour M, Shahsavarinia K. 
Management of pain using magnesium sulphate: a narrative review. Postgrad 
Med. 2022; 134(3):260–6.  
66.  
Kosucu M, Tugcugil E, Arslan E, Omur S, Livaoglu M. Effects of 
perioperative magnesium sulfate with controlled hypotension on 
intraoperative bleeding and postoperative ecchymosis and edema in open 
rhinoplasty. Am J Otolaryngol - Head Neck Med Surg. 2020; 41(6):102722.  
67.  
Arumugam S, Takkellapati A, John L. Magnesium sulfate toxicity – Are 
serum levels infallible? J Obstet Anaesth Crit Care. 2021; 11(1):43.  
68.  
Silva Filho SE, Klinsky OS, Gonzalez MAMC, Dainez S, Angelis F, Vieira 
JE. Strategy for Calculating Magnesium Sulfate Dose in Obese Patients: A 
Randomized Blinded Trial. Anesthesiol Res Pract. 2022;2022.  
69.  
Pascoal ACF, Katz L, Pinto MH, Santos CA, Braga LCO, Maia SB, et al. 
Serum magnesium levels during magnesium sulfate infusion at 1gram/hour 
versus 2grams/hour as a maintenance dose to prevent eclampsia in women 
with severe preeclampsia: A randomized clinical trial. Med (United States). 
2019; 98(32).  
70.  
Reddi A. Fluid , Electrolyte and Acid-Base Disorders. 3rd ed. Cham: 
Springer; 2023. 377–381 p.  
71.  
Chestnut D, Wong C, Tsen L, Ngan Kee W, Beilin Y, Mhyre J, et al. 
Chestnut's Obstetric Anesthesia: Principles and Practice. 6th ed. Philadelphia: 
ElSevier; 2019.  
72.  
Sun H, Jin T, Wu X, Yang L, Zuo Y, Liao R. Efficacy of magnesium sulfate 
as an adjuvant to rocuronium in general anaesthesia: a meta-analysis. J Int 
Med Res. 2021; 49(7).  

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73.  
Queiroz Rangel Micuci AJ, Verçosa N, Filho PAG, De Boer HD, Barbosa 
DD, Cavalcanti IL. Effect of pretreatment with magnesium sulphate on the 
duration of intense and deep neuromuscular blockade with rocuronium: A 
randomised controlled trial. Eur J Anaesthesiol. 2019; 36(7):502–8.  
74.  
Akbudak IH, Yilmaz S, Ilhan S, Tanriverdi SY, Erdem E. The effect of 
preemptive magnesium sulfate on postoperative pain in patients undergoing 
mastectomy: a clinical trial. Eur Rev Med Pharmacol Sci. 2023; 
27(17):7907–13.  
75.  
Benevides ML, Fialho DC, Linck D, Oliveira AL, Ramalho DHV, Benevides 
MM. Intravenous magnesium sulfate for postoperative analgesia after 
abdominal hysterectomy under spinal anesthesia: a randomized, double-
blind trial. Brazilian J Anesthesiol (English Ed. 2021; 71(5):498–504.  

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COMPARISON BETWEEN INTRAVENOUS MAGNESIUM 
SULFATE ADMINISTRATION WITH INTRAVENOUS 
DEXMEDETOMIDINE TO REDUCE CONSCIOUS 
RECOVERY AGITATION IN ADULT PATIENTS 
UNDERGOING OTORHINOLARYNGOLOGY SURGERY  
 
This research information sheet explains the purpose, procedure and usefulness of 
the research, so that you understand the research that will take place and can decide 
whether to participate or not. This sheet also contains about the rights of patients 
and our responsibilities as researchers in the implementation of this research. 
 
Research Objectives 
Agitation of conscious recovery or restless agitation during conscious recovery is a 
state that includes disturbing states, disorientation, aimless movements, inability to 
calm down, rebellious, and confused during the initial recovery from general 
anesthesia. Although it is commonly found in pediatric patients, it can occur in the 
adult population. The incidence rate increases in several types of surgeries, one of 
which is ear, nose, and throat surgery. This noisy incident of restless restlessness 
regaining consciousness causes undesirable consequences, such as injuries due to 
falls or the removal of medical instruments.  
There are several drugs that can reduce the incidence of restless restlessness and 
regaining consciousness, including the administration of dexmedetomidine or 
magnesium sulfate during general anesthesia. Until now, dexmedetomidine is the 
best standard for the prevention of restlessness and regaining consciousness. 
However, there are some drawbacks to dexmedetomidine such as its high price, 
Appendix 1. Research Explanation Sheet 

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uneven availability in Indonesia, and the time to fully recover from general 
anesthesia which is slightly extended. 
Magnesium sulfate is a cost-effective alternative to preventing anxiety, restlessness, 
and recovering consciousness that is spread evenly throughout Indonesia. Several 
studies have proven that magnesium sulfate is effective in preventing restless noise. 
However, there has been no research that proves whether magnesium sulfate is no 
less good than dexmedetomidine in preventing restlessness from regaining 
consciousness. 
The study will be conducted by the Department of Anesthesiology and Intensive 
Therapy FKUI of Dr. Cipto Mangunkusumo Hospital Jakarta which aims to 
compare the effects of magnesium sulfate administration with dexmedetomidine to 
prevent the occurrence of restless noise when recovering from consciousness in 
patients undergoing ear, nose and throat surgery. With the hope that magnesium 
sulfate can be used as an alternative that is no less good than dexmedetomidine. 
 
Research procedure 
After getting an explanation from the research team, if you agree to participate, you 
can sign this consent letter form stating that you have been given an explanation of 
this research and are willing to participate. If you agree to participate and have 
signed the consent letter form for this research, you can freely withdraw from this 
study at any time. If you refuse to participate or withdraw from this study, the 
decision will not affect your relationship with me and will not affect the services 
that apply at this hospital. 
Participating patients are patients who will undergo general anesthesia to undergo 
ear, nose, and throat surgery. You will be prepared for surgery and anesthesia as 
usual. In this study, all participants will be randomly divided into 2 groups. During 
anesthesia and the act of getting additional anesthetics according to the group 
allocation, the first group will be given magnesium infusions with a dose of 20 
mg/kg/hour starting from the beginning of anesthesia. The second group will be 
given dexmedetomidine infusion at a dose of 0.5 mcg/kg/hour. Throughout the 

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operation, you will be given anesthesia as usual and vital signs are closely 
monitored. When the surgery is complete, all medications are stopped and the 
patient is woken up. Incidents of restless rowdy were recorded from the time the 
patient stopped his medication until 30 minutes after the breathing tube was 
consciously released. In addition to the event of restless noise, the length of time 
the patient was removed from the breathing tube, blood pressure, pulse, amount of 
medication use during surgery (ephedrine, fentanyl, and sevoflurane), and 
postoperative pain score were recorded during this procedure. 
 
Side effects and risks 
The side effects obtained are usually minimal. The dosage of the research drug used 
is not large, but there is still a possibility of drug side effects. Side effects of the 
drug that may be encountered are a drop in pulse and blood pressure as well as a 
slightly elongated wake-up time with an estimated 1-8 minutes. We have prepared 
a handling protocol if this happens. During the action vital signs will be closely 
monitored, so that the side effects of the drug can be treated faster. 
 
Benefits and confidentiality 
The benefit that can be obtained is that you do not experience restless noise after 
postsurgery. If you wake up from surgery without making a fuss, then injuries due 
to restless noise can be minimized. Another benefit provided by these two drugs is 
a good anti-pain effect. 
You will still receive services according to RSCM service standards. All data 
collected in this study will be kept confidential and used for research in accordance 
with permission by the Ethics Committee of the Indonesian Faculty of Medicine. 
Contact Now 
This research was organized by Dr. dr. Riyadh Firdaus, Sp.An-TI, Subsp. NA(K) at 
the Department of Anesthesiology and Intensive Therapy FK UI/RSCM. If you 

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need further information, you can contact dr. Girhanif Amri Yunda at 
085921252918 cellphone number . 
 
Thank you 
 
Dr. dr. Riyadh Firdaus, Sp.An-TI, Subsp. NA(K) 

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CONSENT FORM FOLLOWING RESEARCH 
(INFORMED CONSENT FORM) 
Principal investigator  
: Dr. dr. Riyadh Firdaus, Sp.An-TI, Subsp. NA(K) 
Whistleblower 
: dr. Girhanif Amri Yunda 
Recipient of information 
Subject name 
Date of birth/age 
Gender 
Address 
Phone No. (HP) 
 
:  
: 
: 
: 
: 
NO 
TYPES OF 
INFORMATION 
CONTENTS INFORMATION 
MARK 
1 
Research title 
Comparison 
between 
intravenous 
magnesium sulfate administration with 
intravenous 
dexmedetomidine 
to 
reduce conscious recovery agitation in 
adult 
patients 
undergoing 
otorhinolaryngology surgery 
 
2 
Research objectives Comparing the effects of magnesium 
sulfate 
administration 
with 
dexmedetomidine 
for 
preventing 
restlessness 
(agitation), 
regaining 
consciousness in patients undergoing 
ear, 
nose, 
and 
throat 
surgery 
(otorhinolaryngology) 
 
Appendix 2. Research Participation Consent Sheet 

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3 
Research methods 
and procedures 
1. Dear Sir/Madam/Brother on this 
occasion I ask you to participate in 
this research. The data in this study 
will be guaranteed confidentiality. 
2. Ladies and gentlemen who meet 
the 
research 
requirements 
(acceptance and rejection criteria) 
will be explained about the 
research and asked to fill out a 
participation approval sheet if 
willing. 
3. All 
participants 
will 
be 
randomized into two groups with 
the help of computers.  The 
random results are known by a 
third party, unknown to the 
research team, the anesthesia team, 
and you. There are two groups, 
namely: 
• Group A: 
Participants 
who 
were 
given magnesium sulfate 
infusion 20 mg/kg of body 
weight per hour  
• Group 2: 
Participants 
who 
were 
given 
dexmedetomidine 
infusion 0.5 mcg/kg of 
body weight per hour 
4. You will be asked about your 
smoking history and history of 
psychiatric illness in the room. 
 

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Measurement of vital signs in the 
room. Food fasting is carried out 
for 6 hours and for drinks starts 2 
hours before surgery 
5. You will be prepared for surgery 
according to the routine procedure, 
installed 
2 
infusions 
in 
the 
preparation room. After that you 
will enter the operating room 
6. In the operating room, you will be 
given a research drug according to 
the 
previous 
random 
results, 
namely group A (magnesium 
sulfate) 
or 
group 
B 
(dexmedemidine), 
general 
anesthesia, and will be monitored 
during surgery. Data on vital signs 
and the use of other routine 
common 
anesthetics 
such 
as 
fentanyl, 
sevoflurane, 
and 
ephedrine will be recorded. 
7. After the surgery is over, all 
medications are discontinued and 
the airway tube (endotracheal 
tube) is removed.  The number of 
incidents of restless restlessness 
and regain consciousness will be 
recorded 
from 
the 
time 
the 
medication is stopped up to 30 
minutes after the airway pipe is 
removed. The length of airway 

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pipe discharge was also measured 
since the drug was stopped  
8. You are then taken to a recovering 
room, and will be observed for 1 
hour, to then assess vital signs, 
pain scale and monitored for side 
effects of the medication 
4 
Number of subjects 64 patients  
 
5 
Research time 
April – July 2024 
 
6 
The benefits of the 
research 
include 
benefits 
for 
the 
research subjects 
The benefit that can be obtained is not 
experiencing 
restless 
noise 
after 
postsurgery. If you wake up from 
surgery without making a fuss, then 
injuries due to restless noise can be 
minimized. Another benefit provided 
by these two drugs is a good anti-pain 
effect 
 
7 
Risks & side effects 
in studies 
Both drugs, both magnesium sulfate 
and dexmedetomidine, are widely used 
with a good level of safety. The dosage 
of the drug used is a relatively small 
dose of drugs but still effective in 
preventing restless noise, so that the 
side effects of the drug can be 
minimized. During the operation, we 
will closely monitor your condition so 
that the operation runs smoothly and 
the side effects of the medication can 
be detected quickly. The risks and side 
effects that can occur as experienced 
by patients under general anesthesia 
 

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usually are: decreased blood pressure 
and pulse. Other side effects: the full 
waking time of general anesthesia is 
slightly longer, about 1-8 minutes but 
the patient will wake up more 
comfortably. 
8 
Compensation 
in 
case of side effects 
You will be treated based on the 
protocol of side effects  
 
10 
Data confidentiality All data of this research will be kept 
confidential. Data storage is only 
carried out by the research team and on 
the research team's device, so it can 
only be accessed by the research team 
and not disseminated in any form. 
Presentations of research results in 
scientific meetings/conferences and 
publications in scientific journals will 
not include the name of the research 
subject. However, representatives of 
the 
ethics 
committee, 
and 
the 
governing national authority body will 
have access to the research data for 
verification 
 
11 
Costs incurred by 
the subject 
You are not charged any additional 
fees 
 
12 
Incentives 
for 
subjects 
None 
 

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13 
Name and address 
of the researcher 
and 
telephone 
number 
dr. Girhanif Amri Yunda  
HP Number: 085921252918 
Department of Anesthesiology and 
Intensive Therapy FK UI – RSUPN 
CM.  Jl. Diponegoro No. 71 Central 
Jakarta. 10430. 
 

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After listening to the explanation of the research to be conducted by dr. Girhanif 
Amri Yunda with the title: "Comparison Between Intravenous Magnesium Sulfate 
Administration and Intravenous Dexmedetomidine to Reduce Agitation to Recover 
Consciousness in Adult Patients Undergoing Otorhinolaryngology Surgery", I have 
understood the information well. By signing this form, I agree to be included in the 
above research voluntarily without coercion from any party. If at any time I feel 
aggrieved in any way, I have the right to revoke this agreement.  
 
 
 
Subject name  
 
 
 
Date 
 
 
 
 
Subject signature or thumbprint 
 
 
 
 
 
Name of witness/guardian 
 
 
 
Date 
 
 
 
 
Signature of witness/guardian 
 
 
 

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I have explained to the subject truthfully and honestly the purpose of the research, 
the benefits of the research, the research procedures, as well as the risks, and 
potential inconveniences that may arise (detailed explanation according to what I 
marked above). I have also answered research-related questions as best I can. 
 
 
 
 
_______________________________ 
Signature of the researcher 
(Dr. dr. Riyadh Firdaus, Sp.An-TI, Subsp. NA(K) / 
(dr. Girhanif Amri Yunda) 
 
 
 
 
_______________________ 
Date 
 
 

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COMPARISON BETWEEN INTRAVENOUS MAGNESIUM 
SULFATE ADMINISTRATION WITH INTRAVENOUS 
DEXMEDETOMIDINE TO REDUCE AGITATION OF 
CONSCIOUS RECOVERY IN PATIENTS UNDERGOING 
OTORHINOLARYNGOLOGY SURGERY 
 
A. Registration  
Medical Record No.   
: 
 
 
Research Number 
: 
Surgery Day/Date 
 
: 
 
 
Surgical procedure 
: 
 
Diagnosis 
 
 
: 
 
B.  Identity 
1. Patient's Initials  
 
 
:  
 
2. Date of Birth (Age)  : 
 
3. Gender  
 
 
: L/P* 
4. Height  
 
: 
cm 
5. Weight 
 
:  
kg 
6. IMT 
 
 
 
:  
kg/m2  
7. Diagnosis 
 
 
:  
8. ASA  
 
 
: I/II* 
9. ASA Encryptioners 
 
 
:  
10. Psychological disorders 
 
: Any/None* 
11. Smoking habits 
 
: Any/None* 
12. Type of operation 
 
 
: Rhinology/Otology/Laryngology*  
(* circle according to answer) 
Appendix 3. Research Sheet 

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C. Duration of Perioperative Action 
Duration of operation  
 
 
 
: 
_______ 
hours 
_______menit 
Length of extubation time 
 
 
 
: _______ minutes 
 
D. Intraoperative Sevoflurane Use  
 
Concentration 
(%volume) 
Flow rate 
(liters/min) 
MAC Value 
Postintubation 
 
 
 
At incision 
 
 
 
30 minutes after 
incision 
 
 
 
Shortly before 
the 
gas 
is 
stopped 
 
 
 
 
E. Intraoperative Hemodynamics 
Time 
Average arterial 
pressure 
Pulse rate 
Basic values  
 
 
Pre-induction values 
 
 
Post-induction 
 
 
Postintubation 
 
 
Post-Incision 
 
 
30 minutes post-incision 
 
 
Post-extubation 
 
 
1 hour postoperative 
 
 

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E. Intraoperative amount of ephedrine 
Drug dosage 
(mg) 
Hours 
Average arterial 
pressure 
Pulse rate 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
F. Perioperative Fentanyl Use 
• Intraoperative : ______ micrograms 
• Postoperative : ______ micrograms 
• Total  
: ______ micrograms 
F. Agitation Events 
Score 
Categories 
Description 
+4 
Combative 
Overtly resisting, aggressive, a direct threat to staff. 
+3 
Very agitated 
Removing or removing the endotracheal tube or 
catheter; be aggressive. 
+2 
Agitated 
Aimless frequency movement, against the ventilator. 
+1 
restless 
Anxious but not aggressive or strong movements 
0 
Conscious and 
calm 
Spontaneous full contact 

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-1 
Drowsy 
Not fully conscious, but can remain awake for a long 
time (opening eyes/eye contact) with a loud 
stimulation (>10 seconds). 
-2 
 Light sedation 
Drowsiness but waking up briefly with eye contact to 
sound (<10 seconds) 
-3 
Deep sedation 
There is no response to sound, but there is movement 
or eye opening in response to physical stimuli. 
-4 
Unarousable 
There is no response to sounds or physical stimuli. 
 
SASR Score :  
Onset of agitation 
: ______ minutes 
Duration of agitation : ______ minutes 
What is SASR ≥3? If so, do the heavy agitation rescue protocol and answer question 
G. If not, go directly to question H. 
 
G. Use of Heavy Agitation Rescue Drug (propofol) 
Total Dose of Propofol: ____ mg 
 
G. Postoperative pain value 
Numerical rating scale 
 
 

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Normally-distributed numerical data is presented in a standard intersection ± 
average; abnormally distributed numerical data are presented in median (minimum 
maximum); Categorical data is presented in amounts (percentages). 
 
Table 1. Characteristics of research subjects 
Variable 
Group A (n) Group B (n) 
P 
Age (years) 
X+SD 
X+SD 
X 
Geriatric status (>60 
years) 
 
 
 
Geriatrics 
X (X%) 
X (X%) 
X 
Non-geriatric 
X (X%) 
X (X%) 
X 
Gender 
 
 
 
Male 
X (X%) 
X (X%) 
X 
Women 
X (X%) 
X (X%) 
X 
Weight (Kg) 
X+SD 
X+SD 
X 
Height (Cm) 
X+SD 
X+SD 
X 
BMI 
X+SD 
X+SD 
X 
Obesity status 
 
 
 
Obesity 
X (X%) 
X (X%) 
X 
Non-obesity 
X (X%) 
X (X%) 
X 
ASA physical status 
 
 
 
ASA 1 
X (X%) 
X (X%) 
X 
ASA 2 
X (X%) 
X (X%) 
X 
Duration of operation 
(minutes) 
X+SD 
X+SD 
X 
Smokers 
 
 
 
Yes 
X (X%) 
X (X%) 
X 
No 
X (X%) 
X (X%) 
X 
Appendix 4. Dummy Table 

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Psychological status 
 
 
 
With psychological 
disorders 
X (X%) 
X (X%) 
X 
No 
psychological 
disorders 
X (X%) 
X (X%) 
X 
Type of operation 
 
 
 
Otology 
X (X%) 
X (X%) 
X 
Prhinology 
X (X%) 
X (X%) 
X 
Laryngology 
X (X%) 
X (X%) 
X 
 
Table 2. Comparison of the proportion of emergence agitation events 
Variable 
Group A (n) Group B (n) 
P 
With emergence agitation 
(SASR >1) 
X (X%) 
X (X%) 
X 
No emergence agitation 
(SASR <1) 
X (X%) 
X (X%) 
X 
 
Table 3. Comparison of average hemodynamic parameters 
Variable 
Group A (n) Group B (n) 
P 
Average 
arterial 
pressure  
 
 
 
Pre-induction 
X+SD 
X+SD 
X 
Post-induction 
X+SD 
X+SD 
X 
Postintubation 
X+SD 
X+SD 
X 
Post-Incision 
X+SD 
X+SD 
X 
30 
minutes 
post-
incision 
X+SD 
X+SD 
X 
Post-extubation 
X+SD 
X+SD 
X 
1 hour post-extubation 
X+SD 
X+SD 
X 
Pulse frequency  
 
 
 

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Pre-induction 
X+SD 
X+SD 
X 
Post-induction 
X+SD 
X+SD 
X 
Postintubation 
X+SD 
X+SD 
X 
Post-Incision 
X+SD 
X+SD 
X 
30 
minutes 
post-
incision 
X+SD 
X+SD 
X 
Post-extubation 
X+SD 
X+SD 
X 
1 hour post-extubation 
X+SD 
X+SD 
X 
 
Table 4. Comparison of the proportion of postoperative pain scores 
Variable 
Group A (n) Group B (n) 
P 
VAS <4 
X (X%) 
X (X%) 
X 
VAS >4 
X (X%) 
X (X%) 
X 
 
Table 5. Comparison of the proportions of the frequency of ephedrine use 
Variable 
Group A (n) Group B (n) 
P 
Ephedrine  
X (X%) 
X (X%) 
X 
 
Table 6. Dosage comparison of propofol use in heavy agitation 
Variable 
Group A (n) Group B (n) 
P 
Propofol  
X+SD 
X+SD 
X 
 
 
 

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Table 7. Comparison of the proportion of perioperative fentanyl use 
Variable 
Group A (n) Group B (n) 
P 
Intraoperative 
X (X%) 
X (X%) 
X 
Postoperative 
X (X%) 
X (X%) 
X 
 
Table 8. Comparison of intraoperative sevoflurane use 
Variable 
Group A (n) Group B (n) 
P 
Concentration 
(%volume) 
 
 
 
Postintubation 
X+SD 
X+SD 
X 
At incision 
X+SD 
X+SD 
X 
30 
minutes 
after 
incision 
X+SD 
X+SD 
X 
Shortly before the gas 
is stopped 
X+SD 
X+SD 
X 
Flow rate (liters per 
minute) 
 
 
 
Postintubation 
X+SD 
X+SD 
X 
At incision 
X+SD 
X+SD 
X 
30 
minutes 
after 
incision 
X+SD 
X+SD 
X 
Shortly before the gas 
is stopped 
X+SD 
X+SD 
X 
MAC 
 
 
 
Postintubation 
X+SD 
X+SD 
X 
At incision 
X+SD 
X+SD 
X 
30 
minutes 
after 
incision 
X+SD 
X+SD 
X 
Shortly before the gas 
is stopped 
X+SD 
X+SD 
X 
 

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Table 9. Comparison of the average time of conscious extubation 
Variable 
Group A (n) Group B (n) 
P 
Average 
time 
of 
conscious extubation 
X+SD 
X+SD 
X 

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Principal investigator  
: Dr. dr. Riyadh Firdaus, Sp.An-TI, Subsp. NA(K) 
Researcher II  
: dr. Aino Nindya Auerkari, Sp.An-TI 
Researcher III  
: dr. Girhanif Amri Yunda 
Appendix 5. Research Organizations  

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COMPARISON BETWEEN INTRAVENOUS MAGNESIUM 
SULFATE ADMINISTRATION WITH INTRAVENOUS 
DEXMEDETOMIDINE TO REDUCE AGITATION OF 
CONSCIOUS RECOVERY IN PATIENTS UNDERGOING 
OTORHINOLARYNGOLOGY SURGERY 
 
Yes 
Description 
Percentage 
(%) 
Amount (Rp) 
1 
Shopping for consumables 
56% 
4.384.032 
2 
Cost statistics 
6% 
500.000 
3 
Other operational costs 
38% 
3.057.000 
Total 
7.941.032 
 
 
Yes 
Description 
Justification 
for Use 
Quantity 
Unit 
Price 
(Rp) 
Cost 
Consumables cost 
1 
Kabimidin 
Research 
drugs 
32 vial 
125.843 
4.026.976 
2 
MgSO4 20% 
Research 
drugs 
32 flax 
5.325 
170.400 
3 
Spray 50 mL 
Research 
materials 
64 units 
4.250 
272.000 
Appendix 6. Research Fee Details 

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4 
NaCl 
0.9% 
100 mL 
Research 
materials 
64 flask 
8.000 
512.000 
5 
Extension 
hose 
(perfusor) 
Research 
materials 
64 units 
7.000 
448.000 
6 
Intravenous 
catheter 
Research 
materials 
64 units 
10.500 
672.000 
Subtotal (Rp) 
6.101.376 
Cost statistics 
1 
Consultation 
with 
a 
statistical 
and scientific 
preparation 
supervisor 
Statistical 
consulting 
1 meeting 
500.000 
500.000 
Subtotal (Rp) 
500.000 
Operating costs 
1 
Photocopy of 
the approval 
sheet 
Photocopying 
fees to double 
research 
approvals 
64 units 
1000 
64.000 
2 
Photocopy of 
research 
proposal 
The cost of 
photocopying 
the material 
submitted to 
the supervisor 
and the 
examiner 
board 
15 units 
15.000 
225.000 
3 
Photocopy of 
research 
sheet 
Photocopying 
fee for 
48 units 
1000 
48.000 

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duplicating 
research forms 
4 
Unexpected 
costs 
Anticipate 
additional 
costs 
1 unit 
500.000 
500.000 
5 
Cost 
of 
research staff 
Cost for the 
OK team that 
inputs data 
64 samples 
30.000 
1.920.000 
6 
Ethical 
licensing 
management 
Research 
licensing 
1 unit 
300.000 
300.000 
Subtotal 
3.057.000