Surgery Book


Richmond Agitation Sedation Scale

Aka: Richmond Agitation Sedation Scale, RASS, Modified RASS, mRASS
  1. Indications
    1. Intensive care monitoring of sedation
    2. Delirium evaluation in the Emergency Department
      1. Score other than 0, has a Test Sensitivity of 64% and Test Specificity of 93% for Delirium in ED
      2. Han (2015) Acad Emerg Med 22(7): 878-82 [PubMed]
  2. Scoring
    1. Score +4: Combative
      1. Combative or violent
      2. Danger to care team
    2. Score +3: Very Agitated
      1. Pulls or removes tubes or catheters
      2. Aggressive
    3. Score +2: Agitated
      1. Frequent non-purposeful movements
      2. Fights Ventilator
    4. Score +1: Restless
      1. Anxious or apprehensive
      2. Not aggressive
    5. Score 0: Alert and calm
    6. Score -1: Slightly Drowsy
      1. Awakens to voice (e.g. eye opening with eye contact) >10 sec
    7. Score -2: Moderately Drowsy
      1. Light sedation
      2. Briefly awakens to voice (e.g. eye opening with eye contact) <10 sec
    8. Score -3: Severely Drowsy
      1. Moderate sedation
      2. Movement or eye opening to voice
      3. No eye contact
    9. Score -4: Arousable to pain only
      1. Deep Sedation
      2. No response to voice
      3. Movement or eye opening to physical stimulation
    10. Score -5: Unarousable
      1. Unarousable
      2. No response to voice or physical stimulation
  3. References
    1. Sessler (2002) Am J Respir Crit Care Med 166: 1338-44 [PubMed]




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