RASS (Richmond Agitation-Sedation Scale)

David Goldemund M.D.
Updated on 25/11/2023, published on 13/01/2023
  • the test evaluates the quantitative aspect of consciousness and the level of psychomotor activity
    • mostly it is used in mechanically ventilated patients to prevent both over-sedation and under-sedation
  • timing is crucial; sedation should be reduced 1-2 hours prior to testing
  • start with patient observation
    • patient is alert, in a normal state (0)
    • patient is hyperactive (score +1 to +4)
  • if not alert, state the patient’s name and request to open their eyes and look at the speaker
    • patient awakens with sustained eye contact (score –1)
    • patient awakens with eye contact, but not sustained (score –2)
    • patient exhibits any movement in response to voice but no eye contact (score –3)
    • scores -1 to -3 indicate varying degrees of somnolence; the patient responds to verbal stimulus and may be further tested for delirium
  • if the response to verbal stimulation is absent, physically stimulate the patient by shaking the shoulder and/or rubbing the sternum
    • any movement in response to physical stimulation (score –4)
    • no response to any form of stimulation (score –5)
    • scores -4 and -5 correspond to a profound disturbance of consciousness (sopor – coma) and preclude further testing 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

Related Content

You cannot copy content of this page

Send this to a friend
you may find this topic useful: