Table 1 The Richmond Agitation–Sedation Scale (RASS)
Score | Term | Description |
|---|---|---|
+4 | Combative | Overtly combative or violent; immediate danger to staff |
+3 | Very agitated | Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff |
+2 | Agitated | Frequent non-purposeful movement or patient-ventilator dyssynchrony |
+1 | Restless | Anxious or apprehensive but movements not aggressive or vigorous |
0 | Alert and calm | Spontaneously pays attention to caregiver |
-1 | Drowsy | Not fully alert, but has sustained (more than 10 s) awakening, with eye contact, to voice |
-2 | Light sedation | Briefly (less than 10 s) awakens with eye contact to voice |
−3 | Moderate sedation | Any movement (but no eye contact) to voice |
−4 | Deep sedation | No response to voice, but any movement to physical stimulation |
−5 | Unarousable | No response to voice or physical stimulation |