This calculator is for general information and education. It is not medical advice and does not replace the judgment of a doctor, nurse or pharmacist who knows the full clinical picture.
What the RASS measures
The Richmond Agitation-Sedation Scale (RASS) describes how alert, agitated or sedated a patient is. It was developed by Sessler and colleagues at Virginia Commonwealth University in Richmond and published in 2002, then validated in intensive care patients by Ely and colleagues in JAMA in 2003. It is now the most widely used sedation scale in intensive care units, and is also used in emergency departments, palliative care and procedural sedation.
The ten levels
| Score | Term | Description |
|---|---|---|
| +4 | Combative | Violent, immediate danger to staff |
| +3 | Very agitated | Pulls or removes tubes or catheters; aggressive |
| +2 | Agitated | Frequent non-purposeful movement, fights the ventilator |
| +1 | Restless | Anxious, movements not aggressive |
| 0 | Alert and calm | |
| −1 | Drowsy | Sustained awakening to voice, eye contact over 10 seconds |
| −2 | Light sedation | Briefly awakens to voice, eye contact under 10 seconds |
| −3 | Moderate sedation | Movement or eye opening to voice, no eye contact |
| −4 | Deep sedation | No response to voice, movement to physical stimulation |
| −5 | Unarousable | No response to voice or physical stimulation |
How to assess
- Observe the patient for a few seconds. Calm and alert is 0; restless or agitated is +1 to +4.
- If the patient is not alert, say the name and ask the patient to open the eyes and look at you. The length of eye contact separates −1, −2 and −3.
- If there is no response to voice, stimulate physically by shaking the shoulder or rubbing the sternum: some movement is −4, none is −5.
Sedation targets
Current guidelines for adults in intensive care favor light sedation, often a RASS of 0 to −2, because deep sedation is linked with longer ventilation, more delirium and higher mortality. Deeper targets are kept for specific situations such as severe respiratory failure, raised intracranial pressure or status epilepticus.
Link with delirium
The RASS is the first step of the CAM-ICU, the Confusion Assessment Method for the ICU. Delirium can be assessed at a RASS of −3 or above. At −4 or −5 the patient is too sedated, and the assessment is postponed.
Example
A ventilated patient opens the eyes to voice and holds eye contact for about 5 seconds: RASS −2. If the target was −1, the patient is slightly more sedated than planned, and the team may lower the sedative dose.