The following scales are often used in sedated patients to assess the degree of sedation or agitation.
SCALES:
Ramsay Sedation Scale
| Score | Description |
|---|---|
| 1 | Patient is anxious and agitated or restless, or both |
| 2 | Patient is co-operative, oriented, and tranquil |
| 3 | Patient responds to commands only |
| 4 | Patient exhibits brisk response to light glabellar tap or loud auditory stimulus |
| 5 | Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus |
| 6 | Patient exhibits no response |
Richmond Agitation Sedation Scale (RASS)
| 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 | Drowsy | Not fully alert, but has sustained awakening (eye-opening/eye contact) to voice (>10 seconds) |
| -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 |
| -5 | Unarousable | No response to voice or physical stimulation communicate or follow commands |
Riker Sedation-Agitation Scale (SAS)
| Score | Term | Descriptor |
|---|---|---|
| 7 | Dangerous | Pulling at ET tube, trying to remove catheters, climbing over bedrail, striking at staff, thrashing side-to-side |
| 6 | Very agitated | Requiring restraint and frequent verbal reminding of limits, biting ETT |
| 5 | Agitated | Anxious or physically agitated, calms to verbal instructions |
| 4 | Calm and Cooperative | Calm, easily arousable, follows commands |
| 3 | Sedated | Difficult to arouse but awakens to verbal stimuli or gentle shaking, follows simple commands but drifts off again |
| 2 | Very Sedated | Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously |
| 1 | Unarousable | Minimal or no response to noxious stimuli, does not communicate or follow commands |
REFERENCES & FURTHER READING:
- Validating the Sedation-Agitation Scale with the bispectral index and visual analog scale in adult ICU patients after cardiac surgery. Riker RR, Fraser GL, Simmons LE, Wilkins ML. Intensive Care Med 2001; 27:853-858.
- The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RK. Am J Respir Crit Care Med. 2002 Nov 15;166(10):1338-44.
- Ramsay Sedation Scale. Available at the Stanford Palliative Care Website.
- Comparison and agreement between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in evaluating patients’ eligibility for delirium assessment in the ICU. Khan BA, Guzman O, Campbell NL, Walroth T, Tricker J, Hui SL, Perkins A, Zawahiri M, Buckley JD, Farber MO, Ely W, Boustani MA. Chest. 2012 Jul;142(1):48-54.