ADD-ONS / SCALES

RASS (Richmond Agitation-Sedation Scale)

Created 13/01/2023, last revision 13/01/2023

  • the test assesses the quantitative component of consciousness and the level of psychomotor activity
    • mostly it is used in mechanically ventilated patients in order to avoid over and under-sedation
  • timing is important; reduce sedation 1-2h before testing
  • start with observing the patient
    • patient is alert, in the normal state (0)
    • patient is hyperactive (score +1 to +4)
  • if not alert, state the patient’s name and ask him/her to open eyes and look at the speaker
    • patient awakens with sustained eye opening and eye contact (score –1)
    • patient awakens with eye opening and eye contact, but not sustained (score –2)
    • patient has any movement in response to voice but no eye contact (score –3)
    • grades -1 to -3 correspond to somnolence of varying degrees, the patient responds to verbal stimulus and can potentially be further tested for delirium
  • when no response to verbal stimulation, physically stimulate the patient by shaking the shoulder and/or rubbing the sternum
    • any movement to physical stimulation (score –4)
    • no response to any stimulation (score –5)
    • grades -4 and -5 correspond to a more profound disturbance of consciousness (sopor – coma) and the patient cannot be further tested for delirium
RASS (Richmond Agitation-Sedation Scale)
Score Term Description
+4 combative overtly combative, violent, immediate danger to staff
+3 very agitated pulls or removes tube(s) or catheter(s); aggressive
+2 agitated frequent non-purposeful movement; fights ventilator
+1 restless anxious but movements not aggressive vigorous
0 alert and calm
-1 somnolent /drowsy
not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds) Verbal stimulation
-2 light sedation briefly awakens with eye contact to voice (<10 seconds)
-3 moderate sedation movement or eye opening to voice (but no eye contact)
-4 deep sedation no response to voice, but movement or eye opening to physical stimulation physical stimulation
-5 unarousable no response to voice or physical stimulation
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RASS
link: https://www.stroke-manual.com/rass-richmond-agitation-sedation-scale/