Richmond Agitation Sedation Scale (RASS)

Score Term +4 +3 +2 +1
0 -1

Description
Overtly combative, violent, immediate danger to staff Pulls or removes tube(s) or catheter(s); aggressive Frequent non-purposeful movement, fights ventilator Anxious but movements not aggressive vigorous

Combative Very agitated Agitated Restless Alert and calm Drowsy

Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice e10 seconds)

-2
-3

Light sedation Moderate sedation Deep sedation

Briefly awakens with eye contact to voice 10 seconds) Movement or eye opening to voice (but no eye contact) No response to voice, but movement or eye opening to physical stimulation

Verbal Stimulation

-4

-5

Unarousable

No response to voice or physical stimulation

Physical Stimulation

Procedure for RASS Assessment

1. Observe patient a. Patient is alert, restless, or agitated. 2. (score 0 to +4)

Ifnot alert, state patient's name and say to open eyes and look at speaker. b. Patient awakens with sustained eye opening and eye contact. c. Patient awakens with eye opening and eye contact, but not sustained. d. Patient has any movement in response to voice but no eye contact. (score -1) (score -2) (score -3)

3.

When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum. e. Patient has any movement to physical stimulation.
f. Patient has no response to any stimulation.

(score -4) (score -5)

* Sessler CN, Gosnell M, Grap MJ, Brophy GT, O'Neal PV,

166: 1338-1344.

Keane KA et al. The Richmond AgitationSedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med 2002;

* Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S et al. Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale CRASS). JAMA 2003; 289:2983-299l.

ATTACHMENT VI
; __ -...""'""' ~_M-=-""''''',.,~ ..... .__ .. __
w

..-...-"< __"'__ . _"

""f

_~'~.H"">;\

:;.........,._......_ ..-...._1

.__."_ Sed.atio.n/Agl._t3 ion Scale.. -: . --~--..... .t.

-----~- .; .;-.--.--~-"--.-...
O ...-s-~- .-I.~.f -r .

ic

Pedia!r::
r---~-"""""-"""""'-"""""'"

--.-

.....

1.'

*.. "" L ....

..__ .~~..~.-.~---; ..e.--=-.A ...t::.....~S..-. .t.: .. .. .:-d.;"-tt.- ...: ... .. ;~ d .. .... :-=-=:r::..:r.:::..:.' .. .. ....
.:

".-.to.

_~.

~.--~

...

..--;ieveiffi Very Agit~teJ-=--Dhes not

calms down to Verbal instruction.

'calrrt

down despite frequent verbal reminding of lifnits, requires physical restraitits, biting
en.dottacheal tube .. *LevellC Oapge(~u&Agitai~d='''Pu'Uing-;t endotraC.. l1eal 'ttt~,. trying 'to r.m()ye;c~thetet:s".clirnbingovet the bed ttlils,sudking at staff,

thra~hjvg ~i;d~t() ---'~---1 .. si,#..~.

Crying/Thrashing/Restless . Awake, Alert, Calm

Occasionally

drowsy/Easy

to

Level t Level 2 Level 3

Anxious/-AJ:dtated/Restless ------i Cooperative/Oriented Responds to commands

arouse ~~~-~--~----.----~-~~--------~------~----------------Frequently drowsy but arousable Level 4 Brisk response to tactile stimulation or loud noise

Somnolent) Hard to arouse

LevelS

Sluggish response to stimulus or loud noise

tactile

The Sedation Scale is used to assess the

depth of pharmacological sedation

incurred with the use of pharmacologic pain relief agents administered.

An optimal level is 2 or 3. A sedation level of 5 or 6 requires notification of the

physician for immediate intervention-

* Levels 1A. 1Band

t C are used to evaluate patient's agitation level. It is not

intended to. be Ilsedas part of the painmanagementtool~

\